Coroner's Finding: ASTON Marjorie Irene
Deceased
Marjorie Irene Aston
Demographics
86y, female
Date of death
2013-01-05
Finding date
2015-07-17
Cause of death
right subdural haematoma due to blunt head trauma with contributing excessive warfarin anticoagulation
AI-generated summary
An 86-year-old woman died from subdural haematoma following a minor head injury, complicated by excessive warfarin anticoagulation. She was started on warfarin by a cardiologist on 19 December 2012 for atrial fibrillation, but her INR was never monitored between an initial test (INR 1.9) on 21 December and her death on 5 January (INR 12). Critical failures included: the cardiologist's reliance on postal communication with the general practitioner; the cardiologist not copying the general practitioner into INR results; the patient's expectation that her GP would initiate contact; the general practitioner's failure to realise she was on warfarin until 3 January when she presented with haematuria; and crucially, the GP's failure to chase the INR result after requesting it on 4 January. The patient presented to a telehealth service on the morning of death with a fall and head injury while on warfarin with known haematuria, but was not referred to hospital. Her death was preventable through proper INR monitoring or timely recognition and reversal of excessive anticoagulation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- failure to monitor INR levels between 19 December 2012 and 5 January 2013
- cardiologist's reliance on postal communication with general practitioner
- cardiologist's failure to copy general practitioner into INR test results
- general practitioner's lack of knowledge that patient had been commenced on warfarin
- general practitioner's failure to chase INR test result after requesting it
- general practitioner's failure to recognise critical risk of excessive anticoagulation despite haematuria and unmonitored warfarin use
- patient's expectation that general practitioner would initiate contact
- underfilled blood sample tube
- failure to mark INR request as urgent
- prescription of trimethoprim which could potentiate warfarin effect
- Healthdirect operator's failure to enquire about INR monitoring status and recommend hospital admission despite fall with head injury on warfarin
Coroner's recommendations
- Bring findings to attention of Chief Executive Officer of Royal Australian College of General Practitioners, Chair of South Australian State Committee of Royal Australian College of Physicians, and President of Australian Medical Association (SA)
- Reconsider practice whereby specialists prescribe warfarin expecting general practitioners to manage; consider whether general practitioners should both initiate and manage warfarin therapy on specialist advice
- Advise specialists not to place undue reliance on patients informing general practitioners that warfarin has been initiated
- When specialists initiate warfarin but do not manage it, they should immediately advise the general practitioner by efficient means (email, facsimile, or phone) with request for acknowledgement; curtail use of ordinary post and replace with modern communication methods
- General practitioners referring patients to specialists should advise specialists they expect to be informed of warfarin initiation by rapid means and expect to be copied into INR results
- Specialists initiating warfarin therapy and INR testing should ensure the general practitioner is copied into INR test results
- Remind general practitioners that unexplained bleeding in warfarin patients, especially where INR monitoring has been inadequate, requires careful consideration of need for anticoagulation reversal; seek second opinion if in doubt
- Advise medical practitioners to include all relevant clinical information in INR request forms, including signs of excessive anticoagulation and information about previous INR testing (or lack thereof)
Full text
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