Frank Raymond STOCKTON · Prevention of Future Deaths report

On 31/10/2018 I commenced an investigation into the death of Frank Raymond STOCKTON. The investigation concluded at the end of the inquest on 27th June 2019. The conclusion of the inquest as to the medical cause of death was:

1a Epistaxis, asbestos related pulmonary fibrosis (treated – oxygen therapy) and ischaemic heart disease (treated – Warfarin)

b

c

II Asbestos related early malignant mesothelioma

The following determination as to how, when and where the deceased came by his death and conclusion were reached at the conclusion of the inquest.

Mr Stockton was admitted to the Blackpool Victoria Hospital via the Emergency Department on 10th June 2017 with a history of shortness of breath and collapse and with a medical history of pulmonary fibrosis, ischaemic heart disease, atrial fibrillation, calcified pleural plaques and previous myocardial infarction.
During the period of his admission and following his transfer to ward 10 he suffered recurring albeit not continuous epistaxis, the extent of which was not identified clinically and thus the epistaxis was not treated at any time prior to his discharge home on 27th June 2018.
The epistaxis during the period of that admission was caused by the combined effects of: (a) the use of oxygen therapy and a nasal cannula for the delivery of oxygen which, respectively, had the effects of drying the nasal mucosa and causing irritation to the nose; and (b) the fact that for part of that period of admission Mr Stockton was on Warfarin.
In the period between his discharge and his readmission to the Blackpool Victoria Hospital on 20th July 2018 Mr Stockton received non-humidified home oxygen therapy, via a nasal cannula, initially at a flow rate of 4L per minute which was increased to a flow rate of 5L per minute on or about 18th July 2018.
During this period he experienced recurrent epistaxis which was variable in degree and which, again, was occasioned by the combined effects of: (a) the use of oxygen therapy and a nasal cannula for the delivery of oxygen which, respectively, had the effects of drying the nasal mucosa and causing irritation to the nose; and (b) the fact that Mr Stockton was on Warfarin.
The nosebleeds were reported to Mr Stockton’s GP Practice initially on 28th June 2018, a telephone consultation and a home visit were arranged on 4th July 2018 and epistaxis was diagnosed by his General Practitioner on 13th July 2018. An ENT referral letter was written on a non-urgent basis and had not been sent by the time of Mr Stockton’s readmission to hospital.
On 20th July 2018 Mr Stockton developed melena and haematemesis and was transferred by ambulance to the Blackpool Victoria Hospital where his condition deteriorated, culminating in his death at 00.45 hours on 22nd July 2018.
Mr Stockton’s death was caused by the combined effects of: (a) recurrent epistaxis over the period of his first admission (untreated) and following his discharge home; (b) asbestos related pulmonary fibrosis; (c) ischaemic heart disease and was contributed to by the further impact upon his lung function of asbestos related early malignant mesothelioma. Thus his death was contributed to, to more than a minimal, trivial and negligible degree, by: (a) industrial disease (b) a natural cause and (c) the unintended consequences of medical treatment (Warfarin use and oxygen therapy).

[BRIEF SUMMARY OF MATTERS OF CONCERN]

(1) It was the evidence of a number of clinicians who gave evidence in the course of the inquest that they had not come across a death occasioned by epistaxis in the course of their clinical careers. In those circumstances the cause of the deceased’s death may have been unusual. In that regard he received oxygen therapy both in hospital and, following discharge, at home through a nasal cannula and was also prescribed Warfarin on account of his atrial fibrillation. Whilst, for much of the period in question his Internationalised Normalised Ratio fell within the target range of 2.0 – 3.0 he developed epistaxis which, in the context of and in combination with compromised lung and heart function due to pulmonary fibrosis and ischaemic heart disease, caused his death. In the course of preparing statements for the purpose of the inquest 2 practitioners did not identify and/or did not identify the significance of 2 references to nosebleeds (epistaxis) (or the possibility thereof) within the clinical records.
Thus the concern arises that (1) the risks of epistaxis causing or contributing to death, particularly in a patient who is receiving oxygen therapy and/or who is taking Warfarin and/or who has underlying conditions which impair lung and/or heart function and (2) the fact that the risk of death may not be avoided merely on account of the maintenance of a patient’s Internationalised Normalised Ratio within a target range may not be known generally amongst clinicians such that circumstances creating a risk of other deaths will occur or will continue to exist in the future.