Valerie Ann Simmons · Prevention of Future Deaths report

On 20/10/2023, I concluded an inquest into the death of Valerie Ann Simmons who died on 11/01/2023.
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The medical cause of death was recorded as:
1a) Hypovolaemic Shock
1b) Left Thigh Haematoma
1c) Low Molecular Weight Heparin and Warfarin Therapy with high INR for Metallic Mitral Valve Replacement.
II Ischaemic Heart Disease, Congestive Cardiac Failure, Frailty

I recorded a Narrative Conclusion that Mrs Simmons died from a known complication (bleeding) of a necessary medical procedure (anti-coagulation.)

Mrs Simmons was well known to the community nursing team. She had a past medical history that included a mitral valve replacement in 2007 following which she was prescribed warfarin with a target therapeutic INR of 3.5. In December 2022, it was noted her INR levels were sub-therapeutic and so she was prescribed bridging Fragmin therapy. Her NEWS score was recorded as 5. Community nurses attended daily.
On 7/1/23, she had an injection of Fragmin into her left thigh. On 8/1/23, she was found to have developed a large haematoma. In spite of her changed presentation, there were no recorded observations that objectively demonstrated she was otherwise ‘well’.
Her INR was tested on 9/1/23 and found to be 4.9. A doctor attended and advised admission into hospital which Mrs Simmons initially declined.
She subsequently changed her mind but an email to advise the doctor did not reach him. An ambulance was later called, and Mrs Simmons was admitted into Royal Cornwall Hospital. She deteriorated and died in the hospital on 11/1/23.

It was accepted in evidence that:

- Where there was a change in a patient’s presentation, it would be expected that a set of observations would be undertaken and recorded in a patient’s notes;

- Further training related to the risks of hypovolaemia in an anti-coagulated patient would be beneficial.