Non-Inquest findings - DUCHATEL Daniella Jade

26y · Female·Pulmonary thromboembolism due to deep vein thrombosis (left leg) due to fracture of left tibia (surgically treated)

A 26-year-old woman with a tibia fracture died from pulmonary embolism due to deep vein thrombosis. Despite multiple risk factors (obesity, oral contraceptive use, vaping, leg immobilization, prolonged immobility), no formal VTE risk assessment was conducted at emergency presentation or fracture clinic. Blood-thinning prophylaxis was not prescribed pre-operatively despite being strongly indicated by Queensland Health guidelines. Post-operative anticoagulation (aspirin) was prescribed but likely ceased prematurely. The coroner found the death was likely preventable with proper risk assessment and prophylactic medication from first presentation. Key lessons: implement systematic VTE risk assessment tools, prescribe appropriate prophylaxis based on individual risk profiles, provide clear patient education about risks and compliance importance, and ensure consistent application of guidelines across care settings.