Marian DAY · Prevention of Future Deaths report

On Twelfth December 2019 I commenced an investigation into the death of Marian DAY aged 73.

The investigation concluded at the end of the inquest on the 14ᵗʰ August 2020.

The conclusion of the Inquest was a Narrative as follows:

Marian Day died from a massive intra- abdominal haemorrhage, secondary to a vascular malformation of the spleen. This was not detected in life.
Warfarin, an anticoagulant, given to treat her Atrial Fibrillation was continued in hospital when it should have been omitted, as bleeding was suspected. This prescription error has, on a balance of probability, made a contribution to the haemorrhage.

Mrs Marian Day died at Kings Mill Hospital, Nottinghamshire on the 18ᵗʰ November 2019, following an admission on the 13ᵗʰ November 2019.

An initial plan was made in the early hours of the 14ᵗʰ November 2019 to withhold the Warfarin as she had low blood pressure and a likely diagnosis of a gastrointestinal bleed. Later on the 14ᵗʰ Mrs Day moved from the assessment unit to the ward, and despite the Warfarin dose being crossed off on the prescription chart, Warfarin was given that evening.

Mrs Day did not have a Consultant review on the ward until the morning of the 16ᵗʰ November, and there was no further recorded discussion of the plan for anticoagulant management. A further dose of Warfarin was given on the evening of the 15ᵗʰ November, when it should have been omitted.

There was no written ‘Gastro Intestinal haemorrhage protocol’ document placed in the medical records as would be expected, to help prompt review of the anticoagulant management in this situation, as per hospital guidance.

Mrs Day had a sudden collapse on the ward in the early hours of the 18ᵗʰ November. She had a massive bleed into her abdomen at this time, from which she did not recover.

Whilst there has been a detailed Serious Incident review of the circumstances of Mrs Day’s death conducted by the Trust, it remains unclear as to how and why these prescription errors occurred.

It is my view that a similar prescription error could occur again, as there remains a number of different charts and documents that allow for muddled prescribing of, or omission of, anticoagulants, when there are complex medical conditions and concern re likely bleeding.

Whilst the development of an electronic prescribing system may increase the probability of more clarity in prescription of anticoagulants, this is not in place currently. In addition, this alone in my view will not ensure oversight of anticoagulant management, unless other measures are taken to ensure senior review of patients, and a clear prescription plan recorded for all staff to follow.