Staff at Shellharbour Hospital's emergency department failed to give potentially life-saving treatment to two patients who died just days after they were sent home to recover, an inquest has found.
Deputy State Coroner Ian Guy said yesterday Jennifer Channell and Helen Ivanoska had been denied the possible benefit of treatment for deep vein thrombosis (DVT), which ultimately led to their deaths.
Mrs Channell died on April 18, 2005, at her Albion Park home, just two days after she visited the emergency ward with a fractured leg.
In a separate incident nearly six years later, Mrs Ivanoska, from Horsley, died after visiting the emergency department with a fractured knee.
At the end of a three-day inquest into their deaths, Mr Guy yesterday found both women had died from a pulmonary thromboembolism as a result of DVT, which had developed from their leg injuries.
DVT occurs when a blood clot forms inside a vein, and then breaks off and travels through to the heart, blocking an artery.
Mr Guy told the inquest both women had similar risk factors for developing DVT, yet neither patient was given any medication to prevent it from occurring as their doctors had simply not "turned their minds" to the need for such treatment.
Mrs Channell, 48, and Mrs Ivanoska, 59, both attended Shellharbour Hospital emergency department after falling over.
Mrs Channell's fractured leg was placed into a plaster cast while Mrs Ivanoska's injured knee was managed with a splint. Both women were given pain relief and discharged a few hours later.
Two days after Mrs Channell's hospital stint, she collapsed at home and ambulance officers were unable to revive her.
On July 18 last year, just one week after attending the emergency ward, Mrs Ivanoska started having trouble breathing and died before help arrived.
Mr Guy said both women's post-mortem examinations showed similar risk factors, indicating treatment should have been offered to reduce the risk of DVT.
He conceded the pair may have denied the treatment or accepted treatment and still have suffered from DVT and died as a result.
Mrs Channell's treating doctor admitted the risk of DVT "never crossed his mind", stating it was not appropriate to consider the risks at the time as there was "no such practice".
Mrs Ivanoska's treating doctor said even now she believed considering DVT treatment was "not her decision to take".
"It has to come from the policy wise (sic), then we can put it into practice," she said.
Mr Guy told the inquest a risk assessment for DVT should clearly occur in future cases.
He said authorities needed to develop methods for emergency-based staff to consider the risk and consult with patients to devise a treatment plan.
The inquest also highlighted inconsistencies in the use of a health directive for the prevention of DVT in hospitals, requiring doctors to carry out a risk assessment and prescribe treatment.
Mr Guy said the document currently excluded patients being treated in the emergency department.
He said had Mrs Ivanoska been admitted as an inpatient, she would have received a risk assessment.
"The question might fairly be asked why should there be a policy for people admitted as inpatients and no policy for patients treated in emergency when the risk [of DVT] could be the same? There is, in short, no logical answer."
Mr Guy recommended the NSW Minister for Health consider devising a policy addressing the need for patients attending an emergency department with a lower leg fracture to be assessed and treated for the risk of DVT.
He also recommended an education program be developed to remind medical staff that treatment should be designed to meet the clinical needs of a patient, regardless of specific guidelines.