Coronial
VIChospital

Finding into death of Lenin McLarty

Deceased

Lenin McLarty

Demographics

68y, male

Date of death

2007-11-18

Finding date

2013-06-05

Cause of death

Dilated cardiomyopathy with previous aortic valve replacement and aortic graft

AI-generated summary

A 68-year-old man with aortic valve replacement died from undiagnosed dilated cardiomyopathy, with retroperitoneal haemorrhage as a contributing factor. He developed a large perinephric haematoma (1900mL) secondary to over-anticoagulation (INR 3.5, prothrombin 49 seconds) from warfarin. His GP did not receive anticoagulation monitoring results from Austin Health, limiting ability to adjust warfarin dosing. In ED, a registrar appropriately identified over-anticoagulation before CT diagnosis and proactively ordered reversal agents, though Prothrombinex dosing was not documented. Hospital management was appropriate; the haematoma stabilized and patient remained stable until sudden collapse on day 3 in hospital. The preventable clinical lesson is that GPs managing warfarin patients must ensure receipt of INR results and remain alert to bruising and abdominal pain as bleeding signs, especially with elevated INR. ED identification of warfarin toxicity was exemplary.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

cardiothoracic surgeryemergency medicineurologycardiologygeneral practice

Error types

communicationsystemmedication

Drugs involved

warfarinatenololpiroxicamaspirintramadolpropoxypheneparacetamolprothrombinexfresh frozen plasmapacked red blood cellsoxycodoneoxycodone

Clinical conditions

dilated cardiomyopathyover-anticoagulationwarfarin toxicityretroperitoneal haemorrhageperinephric haematomaaortic valve replacementrheumatic aortic valvular diseaseabdominal aortic aneurysm repairpolycystic kidney diseasedistal right common iliac artery aneurysm

Procedures

CT abdominal angiogramaortic valve replacementaortic graft

Contributing factors

  • Retroperitoneal haemorrhage secondary to over-anticoagulation
  • Inadequate anticoagulation monitoring by general practitioners
  • GP did not receive INR/prothrombin results from Austin Health
  • Undiagnosed severe dilated cardiomyopathy
  • INR over-elevation (3.5) in the four months preceding presentation
  • Failure to document Prothrombinex dose on initial order
  • Failure to administer Vitamin K with Prothrombinex reversal

Coroner's recommendations

  1. No formal recommendations made. Northern Hospital had proactively implemented new Prothrombinex guidelines (17 November 2010), introduced mandatory protocol for anticoagulation reversal (April 2010), conducted audit of Prothrombinex dosing (2011), and committed to six-monthly compliance audits.
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