Deceased
PETER HENG DOWE CHIAM
Demographics
77y, male
Coroner
Coroner John Olle
Date of death
2015-09-30
Finding date
2015-09-27
Cause of death
Cerebral infarction (stroke) complicating elective hernia repair
AI-generated summary
A 77-year-old man with atrial fibrillation on warfarin underwent elective hernia repair. Warfarin was appropriately ceased five days pre-operatively. Post-operatively, warfarin was recommenced on day 1 post-op at 5pm. He was discharged home 36 hours later with unclear communication about INR monitoring responsibility between the hospital, GP, and pathology service. He suffered a massive ischaemic stroke on day 4 post-op with an INR of 1.0 (sub-therapeutic). The coroner found the pre-operative anticoagulation plan appropriate but identified poor communication regarding post-operative warfarin management and INR monitoring as a gap. However, given the short 36-hour window before stroke onset, optimal discharge communication would likely not have prevented the outcome, as INR testing and dose adjustment could not have occurred in that timeframe.
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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