Finding into death of Alan Victor Webster

81y · Male·Intracerebral haemorrhage in the setting of heparinisation for subclavian artery thrombosis

81-year-old Alan Webster with atrial fibrillation on long-term Warfarin underwent colonoscopy in August 2011. His anticoagulation was interrupted and bridging Clexane prescribed. Post-operatively, critically sub-optimal communication between the gastroenterologist Dr M., general practitioner Dr L., and pathology laboratory Melbourne Pathology contributed to inadequate anticoagulation management. The patient did not understand post-operative instructions, the GP was unaware of his role, and the pathology lab lacked medical history regarding previous thromboembolism. Sub-therapeutic INR led to subclavian artery thrombosis requiring embolectomy, followed by heparinization which caused intracerebral haemorrhage and death. Key lessons: written post-operative anticoagulation instructions, direct specialist-to-GP communication, and provision of complete medical history to pathology laboratories are essential.