Mr. Alun Walters · Prevention of Future Deaths report

On the 27th March, 2015 I commenced an investigation into the death of Mr. Alun Walters. The investigation concluded at the end of the inquest on the 26th June, 2015. The conclusion of the inquest was ‘A gastro-intestinal haemorrhage in the circumstance of suspected elevated levels of Warfarin and failed INR monitoring’.

Mr. Alun Walters had longstanding mental health difficulties and alcohol misuse for which he was receiving community psychiatric support. He had been prescribed Warfarin as an anticoagulation therapy since 2011 following the receipt of a metallic heart valve. Mr. Walters was aware of the need for regular INR testing. He joined the Lawn Medical Practice in 2012 and received weekly Warfarin prescriptions from the Practice. The Practice was contracted by the Aneurin Bevan University Health Board to provide INR testing, dosing and prescriptions. Regular INR tests were undertaken until November 2013. In December 2013 Mr. Walters failed to attend for his routine INR test which triggered contact by the Practice advising him to continue his INR testing. No further tests were actually undertaken by the Practice although his prescriptions continued.

In January, 2015 ████████, the Practice’s Health Care Assistance, happened to see Mr. Walters in town. She noted that she had an INR test at the Practice since November 2013 and immediately alerted ████████ GP. In consequence, Mr. Walters was contacted by ████████ on 30 January, 2015 advising that he urgently needed to attend for INR testing or GP consultation. On 29th January, 2015 the GP Practice’s computer prescription data base for Mr. Walters noted that Warfarin was discontinued. A total of 51 prescriptions had been provided to Mr. Walters without the benefit of dosage assessment following INR testing.
Pharmacist, ████████ of the Rhymney Pharmacy Ltd. noted that Warfarin, a longstanding prescription for Mr. Walters, had been dropped from Mr. Walter’s prescription list. Believing this to be an error, he continued to provide it. The GP Practice had not notified the Pharmacy that Mr. Walter’s longstanding prescription of Warfarin had been discontinued. Both at Inquest and during interview with the Aneurin Bevan University Health Board’s Pharmacy Advisors, ████████ admitted that Warfarin was supplied to Mr. Walters in February to April, 2015 without a valid prescription. ████████ confirmed at Inquest that he was not aware of the National Patient Safety Agency’s Safety Alert No. 18 entitled ‘Actions than can make Anticoagulation Therapy Safer’ dated 27.03.07 which states -
‘Ensure that before dispensing a repeat prescription for anti-coagulation medication, they check that the patient’s INR is being monitored regularly and that it is at a safe level for the repeat prescription to be dispensed’.

The Lawn Medical Practice -
(1) failed to use any computer software programmes to support its prescription decisions;
(2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register;
(3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and
(4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing.