Dorothy Delaney · Prevention of Future Deaths report

On the 18th June 2015 I commenced an investigation into the death of Dorothy Delaney, born on the 20th July 1928.

The investigation concluded at the end of the inquest on the 18th September 2015.

The Medical Cause of Death was:

1a Spontaneous Intracerebral Haemorrhage
1b Amyloid Angiopathy
2 Anti Coagulation, Atrial Fibrillation

The conclusion of the inquest was that Dorothy Delaney died as a consequence of naturally occurring disease exacerbated by a recognised complication of anticoagulation therapy, in circumstances where antiplatelet medication was prescribed and administered.

At around 10.20 hours on the 11th June 2015 Mrs Dorothy Delaney, who had been prescribed Rivaroxaban, an anticoagulant, following her diagnosis of atrial fibrillation in March 2015, and who was prescribed Clopidogrel, an antiplatelet medication due to previous transient ischaemic attacks, was found in a collapsed condition at her home address at Ash Tree House Care Home, Warwick Drive, Hindley in Wigan. She was transferred to the Salford Royal Hospital, Salford where she was diagnosed as having suffered a large intracerebral haemorrhage. Her condition deteriorated and she died later that day at 13.10 hours.

1. During the inquest evidence was heard that:

i. Dorothy Delaney became a patient at Alexander House Health Centre, Platt Bridge Health Centre, Rivington Avenue, Platt Bridge, Wigan in August 2013. At that time she was prescribed Clopidogrel, an antiplatelet medication, by her previous general practitioner, due to her history of transient ischaemic attack. This prescription continued to be given by her general practitioner at Alexander House Health Centre up until her death on the 11th June 2015.

ii. In March 2015 Mrs Delaney was diagnosed with atrial fibrillation and as a result was prescribed Rivaroxaban, an anticoagulant, by her general practitioner at Alexander House Health Centre, which she continued to take up until her death.

iii. The Consultant Neuropathologist gave evidence during the inquest that Mrs Delaney had died as a consequence of a spontaneous intracerebral haemorrhage which had been caused by amyloid angiopathy, which is naturally occurring disease of the vessels within the brain that can cause the vessels to rupture, resulting in haemorrhage. Evidence was given that when a person who suffers from amyloid angiopathy takes anticoagulation medication there is an enhanced risk of a haemorrhage occurring. The fact that Mrs Delaney was taking Rivaroxaban was determined to be a contributory factor in her death. Evidence was also given that there is an increased risk of bleeding when a person takes both antiplatelet and anticoagulant medication together.

iv. The policy adopted at Salford Royal Hospital, Salford is that if a person who is prescribed antiplatelet medication requires anticoagulation therapy, they would discontinue one of the medications, in order to reduce the risk of a haemorrhage, unless there is a specific reason why both should be prescribed at the same time.

v. Guidance provided by the National Institute for Health and Care for oral anticoagulation was referred to during the inquest and this guidance states that if a person is prescribed Rivaroxaban there is an increased risk of bleeding if anti platelet medication, such as Clopidogrel, it is taken at the same time. The Guidance states that the use of both medications should be avoided, except on specialist advice.

vi. Following Mrs Delaney’s diagnosis of atrial fibrillation and the subsequent prescription of Rivaroxaban, no specialist advice was sought regarding the appropriateness of continuing to prescribe both Clopidogrel and Rivaroxaban together. Evidence was given at the inquest that advice is not sought on an individual basis for patients at Alexander House Health Centre who are prescribed both Clopidogrel and Rivaroxaban as they rely on advice previously sought in respect of other patients in similar circumstances.

2. I therefore have concerns that there are patients under the care of Alexander House Health Centre who are being prescribed both anticoagulation therapy and antiplatelet medication at the same time, which increases the risk of a haemorrhage occurring, in circumstances where specialist advice has not been sought, taking into account the individual patient’s previous medical history and circumstances.

3. I therefore request ████████ review the treatment of all patients in his practice who are being treated with Clopidogrel, or any other antiplatelet medication at the same time as Rivaroxaban, or any other anticoagulation medication, having regard to the NICE guidelines in relation to oral anticoagulation.