Natalie Rae lived just one day after being discharged after surgery for leg pain.

Natalie Rae died from a blood clot the day after being discharged from a Counties Manukau District Health Board hospital following a series of scans that were negative for clots.

The 27-year-old died in front of her son Braden, then aged 6, and her mother Iris. An autopsy found she died of a blood clot in her lung.

"Her last words to me were 'Mum, I'm scared, I can't breathe'. That just haunts me," said Mrs Rae, of Half Moon Bay in Southeast Auckland, who approached the Herald after reading the start of our hospital mortality series.

"Braden's 9 now. He's still really suffering. He misses her badly."


More than two years after her daughter's death in March 2010, Mrs Rae is dissatisfied with the official investigations and believes no one has been held accountable. The doctor she considers most culpable is no longer registered to practise in New Zealand.

She disagrees with Health and Disability Commissioner Anthony Hill's view that her daughter's medical care was mostly reasonable and she has complained to the Ombudsmen about how the commissioner handled the case. She said Mr Hill's office had last week told her it was now looking further at some matters she had raised.

Mrs Rae said Natalie had a range of risk factors for deep-vein thrombosis (DVT), blood clots that can break up and block a blood vessel in the lungs. These included smoking, obesity, family history of DVT, oestrogen therapy, recent surgery and the associated immobility. Her doctors knew this.

In February 2010, Natalie had ACC-funded right ankle surgery at a private hospital to fix recurring problems resulting from a netball injury.

Four weeks later her surgeon sent her to Middlemore Hospital for an ultrasound scan because of swelling and pain in her right calf. He thought she probably had a DVT. A D-dimer blood test, which can indicate evidence of a clot - but also other causes - was strongly positive.

An ultrasound doctor could not do a scan that day, so Natalie was given a blood-thinning drug, allowed to go home overnight and had the scan the next day. The scan report findings included, "No DVT".

In the following days, two more scans were done, an MRI and, in the midst of those, a leg operation at the DHB to deal with what was thought to be a tissue problem causing the pain.

But the day after being discharged home, Natalie collapsed and couldn't be resuscitated, says a "serious and sentinel event" investigation report by the DHB. It found that one of the "root causes" of the "event" was the contribution of the negative ultrasound tests to the decision not to treat Natalie for DVT despite the high probability that she did have a clot.

The DHB later said the fallibility of ultrasound scans to diagnose DVT had not been fully understood. Pre-scan DVT probability was now taken into account and risk factors were listed on the scan request form.

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