Margaret Hions · Prevention of Future Deaths report

On 3rd September 2013 I commenced an investigation into the death of Margaret Hions . The investigation concluded at the end of the inquest on 12th February 2016. The conclusion of the inquest was a narrative conclusion namely that:
Margaret Hions died on 27th August 2013 from pulmonary infarction and coronary artery atherosclerosis in an elderly woman who had sustained breakdown of a left gluteal haematoma caused by tinzaparin therapy. There were shortcomings in the management of her care at Glangwili Hospital.

(1) Mrs Hions was admitted to Glangwili Hospital on 1 July 2013 with increasing shortness of breath, decreased mobility, loss of appetite, nausea and vomiting. At the time of her admission she was prescribed warfarin. A decision was made to replace warfarin with tinzaparin.
(2) Mrs Hions remained in hospital and during her admission a large bruise was observed which expanded rapidly.
(3) As a result of this the tinzaparin was stopped.
(4) Mrs Hions was subsequently transferred to the Prince Philip Hospital where she passed away on 27th August 2013.

(1) That there should be a review of the current Health Board practice in the prescribing of tinzaparin medication and the monitoring of blood levels.
(2) That the importance of monitoring creatinine clearance as per Health Board clinical pharmacy policy to be reiterated to medical team and pharmacists.
These matters were identified by a Root Cause Analysis Investigation report but it was unclear at the inquest whether these recommendations have yet been acted upon.