Deceased
Selvamalar Murugathasan
Demographics
43y, female
Coroner
Coroner Audrey Jamieson
Date of death
2009-03-13
Finding date
2012-04-19
Cause of death
Acute thrombosis of a prosthetic mitral valve
AI-generated summary
A 43-year-old woman with prosthetic mitral and aortic valves due to rheumatic heart disease died from acute thrombosis of her prosthetic mitral valve following cessation and recommencement of warfarin for IVF treatment. A critical breakdown in communication occurred between her IVF specialist and general practitioner regarding anticoagulation management after the IVF cycle. Each clinician assumed the other was managing warfarin dosing and recommencement, and neither verified the plan directly with the patient. The patient had previous experience with perioperative anticoagulation changes, but this assumption of understanding proved dangerous. Clear communication protocols between multiple treating clinicians, explicit assignment of responsibility for anticoagulation monitoring, and patient education in lay language are essential when managing patients on critical anticoagulation therapy, particularly those with language barriers.
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
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