Deceased
Lenin McLarty
Demographics
68y, male
Coroner
Coroner Dr Jane Hendtlass
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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