Coroner's Finding: Newell, Warren James
Deceased
Warren James Newell
Demographics
71y, male
Date of death
2022-10-01
Finding date
2024-09-30
Cause of death
raised intracranial pressure caused by left frontal-temporal-parietal subdural haemorrhage secondary to coagulopathy from supra-therapeutic enoxaparin dosing, previous rivaroxaban therapy, and dual antiplatelet agents
AI-generated summary
Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. However, he was prescribed an excessive dose of enoxaparin (100 mg twice daily) instead of the weight-appropriate dose of 70 mg twice daily. This supra-therapeutic anticoagulation, combined with rivaroxaban and dual antiplatelet agents, likely contributed to a catastrophic left frontal-temporal-parietal subdural haemorrhage that developed on 1 October 2022, resulting in death. Key preventable factors included failure to weigh the patient on admission, absence of electronic prescribing safeguards, and lack of pharmacist review. Implementation of weight-based dosing protocols, e-prescribing systems, and pharmacy services could have prevented this tragic outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- excessive enoxaparin dose (100 mg twice daily instead of 70 mg twice daily)
- failure to weigh patient on admission
- weight not recorded on medication chart
- no electronic prescribing system to flag excessive dose
- no pharmacist for emergency department to identify dosing error
- combination of anticoagulation (rivaroxaban, enoxaparin) and dual antiplatelet therapy (aspirin, clopidogrel) creating significant bleeding risk
Coroner's recommendations
- Improved practices for recording patient weight on admission
- Placement of correct enoxaparin dosages in guidelines
- Implementation of electronic prescribing system
- Establishment of pharmacist service for emergency department
- Alleviation of workload in relevant circumstances
- Tasmanian Health Service and MCH to revisit RCA recommendations and assess whether further action should be taken to enhance accurate use of drugs
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