ABSTRACT
This is the most common cause of death recorded in this report; 50 cases are reported. The authors state that substandard care was present in many cases; exactly how many, they cannot specify, because of incomplete documentation. Substandard care falls into three categories: • a failure to diagnose, despite risk factors and suggestive symptoms and
signs; • a failure to treat properly. This is rare; once diagnosed, thrombosis is
usually adequately managed; • a failure to provide prophylactic treatment appropriate to the level of risk.
