Finding into death of Alan Victor Webster

Contributing factors

• Ineffective communication by Dr M. with patient regarding post-operative anticoagulation therapy
• Absence of clear written post-operative anticoagulation instructions
• Dr M. did not communicate with Dr L. about need for post-operative anticoagulation oversight
• Dr L. unaware of timing of colonoscopy and anticoagulation transition therapy
• Melbourne Pathology lacked complete information about patient's medical history, particularly previous thromboembolism
• Patient did not understand post-operative instructions regarding continuation of Clexane until INR therapeutic
• Post-operative INR remained sub-therapeutic on 24 and 26 August 2011
• Subsequent development of subclavian artery thrombosis requiring embolectomy
• Heparinisation post-embolectomy led to intracerebral haemorrhage

Coroner's recommendations

1. RACGP to remind members of need to identify and communicate clinically relevant information to pathology laboratories monitoring anticoagulation therapy
2. RACGP to consider recommending that patients on anticoagulation therapy be reviewed by a haematologist at regular intervals
3. RACGP-Haematologists to consider recommending that haematologists proactively seek annual updates from GPs about long-term anticoagulation therapy patients, including indications, adverse clotting events, planned surgery, and medication changes
4. Royal College of Pathologists of Australasia to consider recommending that pathology laboratories proactively seek annual updates from GPs about long-term anticoagulation therapy patients, including indications, adverse clotting events, planned surgery, and medication changes
5. Policy or procedure between Dr M. and Reservoir Private Hospital addressing provision of information to patients on pre- and post-operative anticoagulation therapy, manner of information provision, medication dosing and timing, and assignment of responsibility for monitoring anticoagulation and patient adherence