Finding into death of Darren Templeton

51y · Male·pulmonary thromboembolus secondary to left deep vein thrombosis

Darren Templeton, a 51-year-old man with obesity (BMI 31.5), died of pulmonary thromboembolism and left deep vein thrombosis six days after undergoing left knee arthroscopy. Critical clinical lessons: (1) VTE risk assessment forms were not completed on admission despite hospital policy; (2) pharmacological VTE prophylaxis was not provided despite high-risk status (obesity, major orthopaedic surgery); (3) aspirin monotherapy is inadequate for VTE prevention in knee replacement; (4) post-discharge breathlessness was dismissed and not investigated; (5) lack of formal documented VTE risk stratification meant individualised prophylaxis decisions were not reviewed. The coroner could not definitively state that escalated prophylaxis would have prevented death given controversial guidelines, but emphasised that formal documented risk assessment at admission was essential standard practice that failed to occur.