Coroner's Finding: BRUNT Sidney

Contributing factors

• failure to monitor INR levels during warfarin therapy
• excessive anticoagulation with INR greater than 10
• lack of patient education regarding need for monitoring
• delayed recognition of intracranial bleeding on presentation
• examining physician unaware of warfarinisation status
• inadequate supervision of overseas trained practitioner
• poor communication of warfarin status in clinical records

Coroner's recommendations

1. That the Department of Health, in conjunction with the Medical Board of South Australia, conduct an investigation into the level of knowledge, expertise and experience of overseas trained medical practitioners in respect of warfarin prescription and monitoring, and implement measures to ensure overseas trained practitioners demonstrate satisfactory knowledge before practice
2. That the Department of Health, in conjunction with the Pharmacy Board of South Australia, give consideration to whether pharmacists filling warfarin prescriptions should impart oral or written information regarding the need for anticoagulation monitoring
3. That the Department of Health promulgate a brochure containing information on the need for warfarin monitoring, to be made available for distribution by general practitioners to patients
4. That the management of Port Lincoln Hospital review the efficiency of its after-hours radiographical and radiological services
5. That the management of Port Lincoln Hospital undertake training of medical practitioner(s) to enable them to perform emergency parietal burr hole procedures
6. That the management of Port Lincoln Hospital ensure that warfarin or other anticoagulant therapy is displayed prominently in the patient's clinical record and specifically drawn to the attention of the examining medical practitioner