Finding into death of Selvamalar Murugathasan

43y · Female·Acute thrombosis of a prosthetic mitral valve

A 43-year-old woman with prosthetic mitral and aortic valves due to rheumatic heart disease died from acute thrombosis of her prosthetic mitral valve following cessation and recommencement of warfarin for IVF treatment. A critical breakdown in communication occurred between her IVF specialist and general practitioner regarding anticoagulation management after the IVF cycle. Each clinician assumed the other was managing warfarin dosing and recommencement, and neither verified the plan directly with the patient. The patient had previous experience with perioperative anticoagulation changes, but this assumption of understanding proved dangerous. Clear communication protocols between multiple treating clinicians, explicit assignment of responsibility for anticoagulation monitoring, and patient education in lay language are essential when managing patients on critical anticoagulation therapy, particularly those with language barriers.