Coroner's Finding: Ham, Roderick David Charles

59y · Male·pulmonary thromboemboli due to deep vein thrombosis following right hip replacement

A 59-year-old man died from pulmonary thromboembolism following right hip replacement surgery. He had mild polycythaemia and elevated BMI (33.26), both risk factors for deep vein thrombosis. Pre-operatively he was classified as low-risk and received standard thromboprophylaxis (anti-embolic boots, aspirin, early mobilisation). However, an experienced orthopaedic review suggested his polycythaemia and BMI warranted high-risk classification with additional anticoagulation (e.g. warfarin). Additionally, his enoxaparin dose was reduced from 100mg to 70mg twice-daily on day 5 without clear clinical justification, potentially contributing to under-anticoagulation. While the surgeon's initial risk assessment was not unreasonable under 2016 guidelines, clinicians should carefully evaluate cumulative thrombotic risk factors and maintain appropriate anticoagulation dosing in post-operative hip replacement patients.