Coroner's Court of Western Australia

Inquest into the Death of Renee Desiree RUYZING

Inquest into the Death of Renee Desiree RUYZING


Delivered on : 19 October 2020

Delivered at : Perth

Finding of : Deputy State Coroner King

Recommendations : Yes

That the Department of Health place a high priority on ensuring that an appropriate system is implemented in all Western Australian hospitals to ensure as far as practicable that VTE risk is prevented.

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 9 May 2015 Ms Ruyzing fractured her ankle accidently and underwent surgery at Fiona Stanley Hospital to repair the fracture. On 14 June 2015 she died from pulmonary thromboembolism (PE) in association with deep vein thrombosis (DVT) in the recently injured leg. She was 21 years old.

After fracturing her ankle, Ms Ruyzing was admitted to Fiona Stanley Hospital where she was provided with a below-the-knee cast, analgesia and elevation of her ankle. She was administered enoxaparin for three days for DVT prophylaxis. On 13 May 2015, she was transferred to Fremantle to await further reduction of the swelling in her ankle. On the morning of 14 May 2015, she was transferred back to Fiona Stanley Hospital for surgery.

On 15 May 2015, Ms Ruyzing underwent an uncomplicated open reduction and internal fixation of her ankle fracture. She was discharged on the morning of 16 May 2015 with no prescription or instruction for an anti-coagulant despite having risk factors for venous thromboembolism (VTE).

On 29 May 2015, Ms Ruyzing attended the Fiona Stanley Hospital outpatient clinic where the stitches on her ankle were removed and her cast was replaced with a below knee fibreglass cast.

On the evening of 14 June 2015, Ms Ruyzing attended her GP with complaints of palpitation, pleuritic chest pain worsened by deep breathing, shortness of breath and vomiting. She had experienced a similar episode on the previous evening. Her GP was concerned that she may have a pulmonary embolism, so he sent her to the Rockingham General Hospital Emergency Department. Ms Ruyzing went to the hospital and collapsed in the waiting room. Hospital staff administered CPR and transferred to the resuscitation area, but she could not be revived.

The Deputy State Coroner made a recommendation for all hospitals to implement a system of VTE risk assessment and prevention.

Catch-words : VTE Assessment : Prevention of VTE : Thromboprophylaxis : Natural Causes


Last updated: 1-Dec-2020

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