Phyllis Kerry · Prevention of Future Deaths report

On 11 July 2014, I commenced an investigation into the death of Phyllis Kerry, DoB 8 June 1935. The investigation concluded at the end of the inquest on 2 October 2014. The conclusion of the inquest was that the cause of death was :

1a Primary intracerebral haemorrhage
1b Warfarin Treatment
1c Metallic aortic valve and aortic root replacement – ascending aortic aneurysm
2 Hypertension

I recorded a narrative conclusion as follows :

Phyllis Kerry died after suffering a stroke, which was complicated by the Warfarin medication she was on.

Mrs Kerry had a history of heart valve replacement and aortic aneurysm, and was on long-term Warfarin. She was admitted to the ED at Queen’s Medical Centre at 1555 hrs on 28th January 2104, with symptoms suggestive of stroke. She was taken for a CT scan at 1733 hrs. The scan showed a bleed consistent with haemorrhagic stroke.

The ED consultant liaised with neurosurgery and haematology colleagues. Neurosurgery advice was that nothing could be done surgically, but that the effects of the Warfarin should be reversed, and they should be contacted again if her condition deteriorated.

The haematology registrar advised giving Mrs Kerry Vitamin K to reverse the Warfarin. He did not recommend giving Octaplex. He did not discuss the case with his seniors or with neurosurgery colleagues. It was accepted in evidence that Octaplex should have been given, to reduce the effects of the Warfarin more quickly.

Mrs Kerry deteriorated, with dropping GCS, and further CT scanning showed that her bleed had increased significantly. After consultation with neurosurgery colleagues, and discussion with her family, a DNAR order was put in place and Mrs Kerry died – her death being confirmed in the early hours of 31st January 2014.

The haematology registrar gave evidence that he carried out research of his own on 28 January, using Electronic Medicines Compendium, and came to the conclusion that, because of a risk of clotting, it would be better for Mrs Kerry to be given Vitamin K, instead of Octaplex.

I took evidence from a consultant physician, who said that NICE and RCP guidelines state that both Vitamin K and Octaplex should be given in cases of intracerebral haemorrhage in patients anti-coagulated with Warfarin or similar drugs.

The haematology registrar was not aware of these guidelines, and the consultant physician told us that there are no current trust guidelines which cover this – draft guidelines have been withdrawn but not replaced.

I also heard that ████████, a consultant haematologist not involved with this patient, has reviewed the case and advised all haematology and neurosurgery ST doctors that the responsibility for a decision for immediate reversal of Warfarin in patients with CNS bleeds lies with neurosurgery. ████████ gave evidence that he does not consider this practice has been adopted - that it is simply ████████ suggestion – and he does not agree that neurosurgery advice is always necessary in cases like this.

It is clear that there would need to be involvement from several specialties in relation to prescribing Octaplex in particular. Crucially, however, I could not be clear, from the evidence I heard, which specialty would ultimately be responsible for deciding when immediate reversal is called for. It was also clear that there was no guideline or protocol in place which the haematology registrar could have consulted.

(1) Which specialty takes responsibility for deciding when immediate reversal is needed?
(2) The absence of clear guidelines for dealing with patients presenting with intra-cerebral bleeds whilst on Warfarin or similar medication.
(3)The communication of relevant guidelines to relevant staff.

While none of the witnesses I heard from were aware of any relevant guidelines, it is possible that these may in fact already be in existence. Similarly, it may be that draft guidelines are being reviewed. However it was not clear from the evidence when / if these would be finalised.

If there are existing guidelines, it would concern me greatly that the witnesses I heard from were unaware of these, and I take the view that communication of guidelines is as important as the guidelines themselves.