Finding into death of Lenin McLarty

68y · Male·Dilated cardiomyopathy with previous aortic valve replacement and aortic graft

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.