A woman who fell and injured her ankle in a Launceston car park last year was initially treated with a moon boot and crutches before developing deep vein thrombosis and dying in hospital two weeks later, a coroner has found.
Jessica Rose-Aida Borton, a teacher's aide at St Patrick's College in Launceston, fell in a Youngtown car park in October and was given crutches and the boot for her right ankle, which was immobilised.
Eight days later, the 43-year-old was diagnosed with a ruptured Achilles tendon.
She underwent surgery at Launceston General Hospital four days later, which was successfully carried out, but suffered a fluttering in her chest associated with shortness of breath and cold sweats the following morning.
The level of oxygen flowing from her blood to her tissue dropped, and she fell unconscious and suffered a heart attack. She was diagnosed with a massive blood clot in her lung and she died the following afternoon.
Coroner Simon Cooper said a forensic pathologist said the cause of Ms Borton's death was "hypoxic brain injury" as a result of the clot, caused by deep vein thrombosis after her ankle was immobilised.
He said there was no evidence that blood-thinning medication was prescribed, let alone considered, in the process.
"In his report, [coronial medical advisor Anthony] Bell noted that there is no justification for routine use of chemical VTE prophylaxis [blood-thinning medication] for patients undergoing isolated foot and ankle surgery but exceptions relate to Achilles tendon rupture, which certainly calls for, at the very least, individual patient assessment," he said.
"As I noted earlier in this finding, there is no evidence that such prophylactic medication was even considered, let alone prescribed. Had it been, a different outcome for Ms Borton may have been possible."
Mr Cooper said the association of ruptured Achilles tendons, consequent immobilisation and subsequent development of blood clots in the vein needed to be better recognised and understood in the medical community.
St Patrick's College — the school where Ms Borton worked as a music teaching assistant and tutor — paid tribute to her in a Facebook post last year.
"Jessica is fondly remembered as a vibrant and uplifting member of staff, who nurtured the love and passion of music for so many in our community," the school posted.
