Coroner finds Wodonga woman's death while awaiting surgery was preventable

Wodonga woman Mary Morrow, 68, fractured her left ankle on June 23, 2021, while on holiday in Queensland.

She attended a Queensland hospital for initial treatment for venous thromboembolism, known as VTE.

Mrs Morrow returned to Wodonga, then booked in surgery which was cancelled several times.

The 68-year-old collapsed at her home on July 6 of that year and was taken to Albury Wodonga Health, but died.

The coroner investigated her death and the treatment provided.

The prevention unit found her passing would have been preventable, had national standards for treating VTE been consistently followed when she returned to Victoria.

Coroner Leveasque Peterson noted there were no state-based guidelines in Victoria for treating people discharged from hospital with VTE, but such guidelines exist in NSW and Queensland.

The extent to which the dangers of VTE prophylaxis were communicated to the late woman were unclear.

The coroner noted that no doctor at Albury Wodonga Health had taken overall responsibility for that aspect of her care.

Albury Wodonga Health chief medical officer Annabel Martin said if Mrs Morrow had been clearly instructed to take medication daily, her risk of developing deep vein thrombosis would have lowered.

But Dr Martin said it was difficult to confirm what the outcome would have been.

Coroner Peterson said change was needed.

"I support the need for improved and detailed guidance with regard to VTE risk management of patients who are discharged home, including in circumstances where they are temporarily discharged from the emergency department to await surgery in the community to be performed at the same hospital," she said.

Albury Wodonga Health staff have developed a follow-up procedure to ensure discharged patients awaiting surgery are assessed for VTE risk and are given VTE prophylaxis.

"These patients are now reviewed daily by telephone by the orthopaedic team to ensure the risk assessment stays current and any new concerns are addressed," Ms Peterson said.

Other changes have been made by the health service, which the coroner commended.

She agreed the 68-year-old's death was preventable and recommended Albury Wodonga Health continue to review it's system of VTE prevention, and that Safer Care Victoria finalise and publish guidelines on VTE risk management.

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