Stephen Ellis · Prevention of Future Deaths report

On 13th November 2013 I commenced an investigation into the death of Stephen Ellis dob 23rd December 1953. The investigation concluded on the 4th March 2014 and the conclusion was Misadventure. The medical cause of death was 1a Haemopericardium 1b Recent aortic root graft and aortic valve replacement surgery and subsequent warfarinisation 1c Aortic stenosis and aortic root aneurysm 2 Ischaemic and hypertension heart disease, long term haemodialysis due to previous nephrectomies for renal cell carcinoma.

The deceased was admitted to hospital for the necessary heart surgery and he was acknowledged to be a patient with significant co-morbidities. After the surgery he was administered warfarin and thereafter there appears to have been some blood oozing from around the grafted area. When he was administered the warfarin whilst in hospital his INR levels were carefully monitored but upon his release from hospital these checks were reduced to ‘weekly’ and it is apparent that his INR was rising without this being properly noted at the time. The consultant surgeon who performed the operation told me in evidence that warfarin home monitoring kits are readily available and widely used outside the UK. If Mr Ellis had had such a monitoring kit, he may have registered a higher than acceptable INR and this may have been picked up. If so, it was the view of the surgeon, the outcome might have been different and he could have survived.

I believe it would be good practice to supply warfarin home management kits to ‘high risk’ patients who have undergone heart surgery and are subsequently warfarinised. The cost of such kits would probably equate to, or be less than, the cost of hospital monitoring.