Finding into death of Ronald John Wood

68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis

Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to bleeding risk from the cancer and instability during chemotherapy. After surgery, he received appropriate short-term VTE prophylaxis with clexane. However, there was a critical failure to establish an ongoing anticoagulation plan post-discharge despite cumulative VTE risk factors (prior PE, cancer history, major surgery, obesity). Discharge summaries to his GP were silent on anticoagulation management. He died from pulmonary embolism 16 days post-discharge. The hospital's review identified that multiple specialists focused narrowly on their expertise without coordinating overall anticoagulation strategy. Implementation of perioperative physician overview and clear communication protocols to patients and GPs regarding anticoagulation plans could have prevented this death.