Mrs Annie Lloyd · Prevention of Future Deaths report

On the 15 April 2019, I commenced an investigation into the death of Mrs Annie Lloyd. The investigation concluded at the end of the inquest on 19 September 2019. The conclusion of the inquest was a short narrative conclusion of:

Mrs Lloyd was on anti-coagulation medication of warfarin. She was initially on a level of 2.5mg. This was increased by the General Practitioner on the 4 March 2019 to 3mg. She continued to take an additional dosage of 2mg giving a total of 5mg for around 15 days. On the 6 April 2019 she was found unresponsive and admitted to hospital after developing a subdural haematoma. It is not clear on the evidence if the increased dosage of warfarin gave rise to the bleed or that it was a spontaneous bleed or alternatively involved a minor traumatic event.

The cause of death was:

1a Raised Intracranial Pressure
1b Sub Dural Haematoma

i) Mrs Lloyd was on warfarin medication and had a medical history including atrial fibrillation.

ii) She would attend the anti-coagulation clinic at Hospital and her last attendance at the clinic on the 7 March 2019 confirmed she was on 2.5mg per day. She would normally take two brown tablets (1mg) and one white tablet (0.5mg) giving a total of 2.5mg.

iii) On the 4 March 2019, a prescription for 3mg warfarin was issued by her GP, ████████. The GP has suggested that they were informed by family members that she now required a dosage of 3mg.

iv) From the evidence it appears that she was then taking one blue tablet (3mg) and two brown tablets giving a dosage of 5 mg over a period of around two weeks.

v) Mrs Lloyd started to experience chest pain and they went back to the surgery to see the GP on the 1 April 2019. The family told the GP that she had taken 5mg and the GP understood this to mean she had taken a single “one-off” dosage and reduced the dosage to 2mg for a week and then for her to recommence at 2.5mg

vi) Evidence from a Consultant Haematologist confirmed warfarin is used as anticoagulation to prevent strokes and treat atrial fibrillation. The increased warfarin may have caused a bleed or expansion of a bleed caused by another event and we cannot rule out a mild trauma event; although there was no clear evidence of a traumatic injury.

vii) On the 6 April 2019, Mrs Lloyd was found at her home unconscious. On arrival at New Cross Hospital she was deeply comatose. A CT Scan of her head revealed a large subdural haematoma with raised intracranial pressure. Sadly, her condition declined rapidly, and she passed away the same day.

1. Evidence emerged during the inquest that there was an inadequate process in place for checking the patient’s warfarin level dosage. It appears that a “yellow book” confirming the dosage was being copied and the GP issued the prescription without checking this.

2. The GP practice claim to have placed reliance on the family to confirm the dosage required.