Mary Catherine Bloom · Prevention of Future Deaths report

On the 27th February 2014 I commenced an investigation into the death of Mary Catherine Bloom. The investigation concluded at the end of the Inquest on the 30th October 2015. The conclusion of the Inquest was a short form conclusion of natural causes.

Mary Catherine Bloom suffered from dementia. There was a 12 month history of cognitive decline and reduced oral intake. She was admitted to Queens Hospital on the 3rd February 2014 with a history of 3 weeks of significantly reduced oral intake and rapid change in her left leg over 4 hours that morning. The initial impression was that Mrs Bloom was suffering from probable ischemia in the leg, hypovolemia and general decline. She was admitted under the care of the vascular surgical team. The plan in place was for her to receive intravenous fluids, antibiotics and heparin. She was not considered to be a candidate for surgery. The heparin was not expected to reverse the thrombosis but to prevent further deterioration. A loading dose of 5000units of heparin was administered at 17:40 and an infusion of 20,000 units put up at 18:30. Mrs Bloom’s weight was not recorded prior to the administration of heparin or at the time of her admission. The infusion rate was not calculated on the basis of her weight, as it should have been. The Trust policy requires baseline bloods to be taken and then APTT ratios to be checked every 6 hours. Baseline bloods were not taken, as bloods were haemolysing in A & E. They also haemolysed when an attempt was made by the surgical registrar. There was no attempt to repeat bloods after hydration had commenced. There was no consultation with the consultant haematologist in view of Mrs Bloom’s very low weight of 30 kilograms. The haematologist is likely to have advised a reduced loading dose and a reduced infusion rate. Mrs Bloom was admitted to the ward at 20:00 hours and was noted to have a reduced blood pressure at 21.50. The nurse caring for her also questioned the possibility of melena. A doctor attended the ward to review Mrs Bloom and considered that the drop in blood pressure was due to dehydration. Fluids that had been written up previously were not ongoing and therefore he re-sited the cannula and advised that fluids be recommenced at a slightly increased rate. At around 23:45 the nurse caring for Mrs Bloom noted that her condition was deteriorating. She was noted to have passed away at 00:50 on the 4th February 2014. CPR was not attempted as a DNAR order had been put into place by the consultant in charge of her care. There was no discussion with the next of kin prior to placing the DNAR order in her notes.
The pathologist who carried out the post-mortem examination did not find any evidence of bleeding and did not consider that excessive administration of heparin had contributed to Mrs Bloom’s death. The pathologist gave a cause of death 1a dementia and II coronary artery atheroma; mitral valve disease and acute limb ischaemia

1. There was a failure to comply with the Trust’s policy relating to the administration of heparin, by failing to weigh Mrs Bloom prior to the commencing the infusion of heparin.
2. There was a failure to consult a haematologist before the infusion of heparin in view of Mrs Blooms’ very low weight of 30 kilograms. Again, this is required by the Trust policy.
3. It was not possible to take baseline bloods before the commencement of heparin, however, attempts should have been made to retake bloods after hydration had commenced. The Trust policy requires baseline bloods to be taken and for the APTT to be checked after 6 hours.

The consultant haematologist who gave evidence from the Trust confirmed that he should have been consulted, the weight should have been clearly recorded and bloods should have been attempted post-hydration. He agreed that a specially tailored administration of heparin, requiring the documentation of the patient’s weight and APTT ratio would improve the safe administration of the drug.

The poster for the administration of heparin include a direction that:

An obese/underweight patient who weigh over 131 kilograms and under 40 kilograms should be treated on an individual basis. Please seek haematology advice.

This direction is written in very small writing at the bottom of the heparin administration poster. It appears to have been missed by 2 doctors involved in the prescribing of heparin to Mrs Bloom. There is concern that this may have been missed as it was not sufficiently visible on the poster.