Finding into death of Guy Christian Mason

48y · Male·Pulmonary thromboembolism

Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptures in a motorbike collision on 15 August and was WHO Class II obese—both major VTE risk factors. The coroner's investigation identified critical gaps in care: extended VTE prophylaxis was not prescribed upon discharge from the initial hospital admission contrary to organizational guidelines; signs of deep vein thrombosis (foot/ankle swelling and pain) at the outpatient appointment on 6 September were attributed to the initial injury and not investigated; identical symptoms presented to ED the next day were missed due to diagnostic anchoring; pre-operative assessment failed to investigate for DVT despite documented moderate VTE risk. The coroner found that extended VTE prophylaxis per guidelines would have significantly reduced his VTE risk. While acknowledging that VTE is never 100% preventable, the death was possibly preventable with appropriate diagnosis and/or prophylaxis.