Mr B - Non-inquest findings

Contributing factors

• Prescription of rivaroxaban (non-reversible anticoagulant) to patient with faith-based refusal of blood products
• Lack of discussion with patient about anticoagulation risks and transfusion implications
• Concurrent use of naturopathic cherry juice product masking symptoms
• Failure to provide clinical discharge summary to general practitioner
• Delayed recognition of upper gastrointestinal bleeding by general practitioner
• Missed opportunity for earlier escalation after 40% haemoglobin drop on 11 March 2015
• Acute kidney injury making rivaroxaban less suitable than warfarin

Coroner's recommendations

1. Ensure clinician discussion with any patient started on anticoagulation therapy about treatment risks, lack of reversal agents for new oral anticoagulants, and patient's position on accepting blood transfusions
2. Ensure hospital pharmacy department involvement in patient education about anticoagulant risks with documentation in patient chart
3. Require documentation in patient chart of commencement of therapy and reasons for medication decisions
4. Improve documentation of discussions to confirm patient understanding and acceptance of treatment
5. Better document patient requests regarding treatment and discharge preferences
6. Improve communication within treating teams, particularly regarding medication changes and clinical reasoning
7. Advocate for changes to national medication chart patient education box to include reference to new oral anticoagulants and reversal agent status