Michael Blow · Prevention of Future Deaths report

On 3rd March 2016, the Senior Coroner, David Horsley, commenced an investigation into the death of Michael Blow aged 70 years old.

The investigation concluded at the end of the inquest on 4 August 2016 and I recorded a conclusion of Accidental Death.

Michael Blow was admitted to Queen Alexandra Hospital (QAH) on Saturday 27th February just after midnight after falling backwards downstairs at home. In the initial emergency survey he was assessed that he may have an injury to his left shoulder and left chest wall as he was complaining of difficulty in breathing. It was known that he had a history of heart failure and an aortic valve repair & replacement requiring warfarin treatment.

His wife told A&E staff that Mr Blow also had COPD and a suspected chest infection so had been commenced on Doxycycline on Wednesday 24th as recommended by the Bronchiectasis Specialist Nurse at QAH. She also confirmed that Michael’s INR had been checked on Thursday 25th by the warfarin clinic at QAH with a reading of 4.8 against a target of 3-4. As a result, his dose was reduced on Friday 26th and his last dose was taken at home at approx. 6pm.

A chest x-ray confirmed lung contusions and a pneumothorax which required the insertion of a left chest drain. This was to drain air but not blood as the drain was clear at this stage. He was also given 2 units of blood on a preventative basis. A few hours later a chest/abdomen/pelvis CT scan confirmed fractures to the left clavicle and left ribs.

As part of the admission protocol his INR was checked and found to be 5.5. Octaplex 1550 units was given after haematology advice to reverse his high INR. Coupled with the blood transfusion, the Octaplex would have had the effect of quickly reducing his INR level.

Later the same day, Mr Blow was seen by ████████, a consultant surgeon, for review who as part of the care plan requested another INR check. This basic test was not carried out and, in addition, at some point during Saturday, he was also given 2.5 mg of warfarin.

Thereafter appropriate medical attention was given including physiotherapy and pain relief and on Saturday as well as Sunday Mr Blow appeared stable. However, in the early hours of Monday 29th February his condition deteriorated with a suspected further collapse of his lung or contusions to the lung along with a kidney injury. The chest drain now contained blood. His INR at this stage was 9. Eventually Mr Blow went into cardiac arrest and died at 4.40a.m.

The cause of death was 1a) Haemothorax; 1b) Fractured ribs and treatment with warfarin; 2) Ischaemic heart disease, hypertension, COPD and pneumonia.

The post mortem noted a large (2 litre) haematoma in the left chest.

1. The INR test requested by ████████ during the morning of Saturday 27th was never carried out despite being a basic check to baseline Mr Blow’s INR levels and see what effect the Octaplex and blood transfusion plus any antibiotic treatment since admission may have had on his reading to inform further treatment.

2. Warfarin was restarted after ████████ review but was based on an outdated INR reading of 5.5 taken on admission and no account was taken of the Octaplex and blood transfusion plus any other medication such as antibiotics.

3. The clinical evidence heard at the inquest suggests that there is a need to highlight the relevant protocol to junior doctors and nurse practitioners and clarify when to reverse the protocol; who is responsible for this sort of clinical decision; and, importantly when to restart normal warfarin treatment.