Mrs. Hilda May Harris · Prevention of Future Deaths report

On the 16th January, 2015 I commenced an investigation into the death of Mrs. Hilda May Harris. The investigation concluded at the end of the inquest on the 17th April, 2015. The conclusion of the inquest was ‘natural causes exacerbated by prescribed medication’.

Mrs. Harris (86 years) suffered a previous myocardial infarction and cerebral vascular accident. She also suffered from gout. In or around October 2014 her Consultant Cardiologist, ████████ prescribed Warfarin and in consequence, Mrs. Harris' INR levels were monitored by the Community District Nurse team albeit, dose adjustments were the responsibility of the Royal Glamorgan Hospital.

In December 2014, Colchicine and Allopurinol medications were prescribed to treat a flare up of Mrs. Harris’ gout. As either drug could affect the metabolism of Warfarin, an additional INR check was requested by the hospital for the 30.12.14. Although the request was received by the District Nurses’ office, it was not transferred from one sheet of papers to another. In consequence, the INR test was not undertaken.

Mrs. Harris’ daughter, ████████ had been warned by the pharmacist of the importance of INR monitoring when combining Allopurinol with Warfarin. Thus, when the District Nurse failed to undertake the INR test as arranged by the hospital, ████████ contacted the GP surgery to advise of the omission. This message, although noted by the surgery, was not received or not acted upon by the Community District Nurses.

On the 04.01.15, Mrs. Harris suffered a cerebral infarction with an intra-cerebral haemorrhage. Pathologist, ████████ attributed the extensive bleed to elevated levels of Warfarin.

(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another.

(2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable.