Deceased
Ruby Mabel Edwards
Demographics
77y, female
Date of death
2003-09-30
Finding date
2006-04-21
Cause of death
haemorrhagic diathesis due to warfarin toxicity
AI-generated summary
Ruby Mabel Edwards, 77, died from haemorrhagic diathesis due to warfarin toxicity after 84 days in a rural hospital. She had a prosthetic aortic valve requiring anticoagulation. INR monitoring was inadequate: no tests for 36 days (July 28–September 2), then readings of 8.9, 1.2, 8.1, and finally 12 before death. The visiting medical officer (sole GP) faced extreme workload (24/7 on-call, 2300 patients). After high INR readings, he reduced warfarin by only 1 mg to avoid prior over-correction experiences, rather than temporarily cessating or using vitamin K. Clinical lessons: INR should be monitored every 2–3 days during instability; warfarin management in elderly, isolated patients requires system support; point-of-care INR devices and computerised warning systems could assist rural practitioners. The coroner sympathetically concluded the GP provided reasonable care given circumstances, but identified opportunities for improved systems and monitoring protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…
An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…
61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy
A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…
83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…
An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.