Source · Prevention of Future Deaths

Michael Rolfe

Ref: 2022-0280 Date: 7 Sep 2022 Coroner: Paul Cooper Area: Lincolnshire Responses identified: 1 / 1 View PDF

A patient with liver and renal impairment was inappropriately prescribed Rivaroxaban, a contraindicated anticoagulant, significantly increasing bleeding risk and contributing to rectal bleeding and cerebral haemorrhage.

Date 7 Sep 2022

56-day deadline 30 Nov 2022 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

With reference to cause of death at 1b. The deceased had liver impairment due to cirrhosis. He was prescribed the anticoagulant Rivaroxaban for presumed deep vein thrombosis. Within 48 hours he developed rectal bleeding. During his admission to hospital his INR was 1.8 indicating blood was thin. Renal function impaired with a GFR of 39 - baseline 46. Rivaroxaban is contradicted in liver impairment, low platelets and severe renal impairment .(Documented in the product literature and British National Formulary). Consequently, it is represented that the deceased should not have been prescribed Rivaroxaban due to the bleeding risk. Administration of Rivaroxaban to someone with impaired clotting and low platelets would exaggerate the anticoagulant effect and be responsible for the rectal bleed and cerebral haemorrhage that resulted. If accepted the potential inappropriate administration may have led to the cause of death and this has important safety implications that are in the public interest. An action plan to prevent future deaths may be needed.

Responses

1 respondent

Liquorpond Surgery

12 May 2023 PDF

Noted

The surgery provided a factual account of the patient's consultations and treatment based on medical records, noting the author was not involved in the patient's care and is no longer at the practice. (AI summary)

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Dear Sir/Madam Re: Michael Rolfe d.o.b: 16 Apr 1947

Mr Michael James Robert Rolfe, DOB: 16/04/1947 was a 72-year-old gentleman with background of hype1tension, benign prostate hyperplasia, Monoclonal gammopathy of undetermined significance (MGUS), liver cirrhosis due to non-alcoholic steatohepatitis, hepatic encephalopathy and diet-controlled type 2 diabetes mellitus. His regular medications included Bisoprolol once a day, Furosemide once a day, Lansoprazole once a day, Valsartan once a day, lactulose twice a day as required, Colecalciferol / calcium carbonate one tablet twice a day and Aquamax cream. The information in this letter is based on Mr Rolfe's medical notes only as I was not involved in his care and is no longer at Liquorpond surgery. Mr Rolfe had a consultation with on the 21/08/2019 at 12:26 and presented with a swollen and bruised right lower leg which was tender. He denied any trauma to the leg and denied any recent travel or operations. The entry describes that Mr Rolfe had been trying to walk more and he did not have previous history of deep vein thrombosis (DVT). From the examination the right lower leg was swollen and appeared bruised and there was tenderness on palpation. 10 Liquorpond Street Boston Lincolnshire PE21 8UE

Website: \vww.liquorpond-surgery .co. uk

He was started on Rivaroxaban twice a day for suspected deep vein thrombosis and

referred him to have a doppler ultrasound scan of the leg. The referral was done during the consulta.ti on. According to the discharge letter from Pilgrim hospital dated the 22nd of August 2019 at 11 :23, Mr Rolfe attended the DVT clinic on the 22/08/2019 due to right leg tenderness and the ultrasound doppler showed no evidence ofDVT in all venous segments. The discharge letter mentioned that ifRivaroxaban was commenced for DVT cover then it can stop. Mr Rolfe attended the accident and emergency department at Pilgrim hospital on the 23/08/2019 at 16:27 with blood in his stools and passing blood clots. The suspected diagnosis was Hepatic failure or coma. He was intubated by the intensive treatment unit team due to low GCS (Glasgow Coma Scale) score. He sadly passed away on the 24th of August 2019.

Report sections

Investigation and inquest

On 02 September 2019 I commenced an investigation into the death of Michael James Robert ROLFE aged 72. The investigation concluded at the end of the inquest on 07 September 2022. The conclusion of the inquest was that: The deceased presented on 23rd August 2019 to A& E at the Pilgrim Hospital, Boston. A CT scan disclosed an intercranial bleed. He was not a candidate for surgery. Anti coagulants had already been stopped. He declined and died.

Circumstances of the death

Referral from Integrated Assessment Centre, Pilgrim hospital

Due to death within 24hrs of admission. Mr Rolfe is a 72 yr old man admitted on 23/8/19 at 1627hrs with decreasing consciousness. He had a heache one day prior to admission. CT scan showed left cerebellar haemorrhage with intraventricular extension, compression of fourth ventricle and brainstem and obstructive hydrocephalus. ITU team initially intubated and ventilated him. However after discussion with QMC Neurosurgery, who were of the opinion that the position was not treatable. Discussion was had with family. He was extubated at 2350hrs the same day and transferred to the Stroke ward for EOLC. He passed away at 0930hrs on 24/8/19. PMH: TYPE 2 Diabetes mellitus, hypertension, non alcoholic steato hepatitis, hepatic encephalopathy, monoclonal gammopathy of undetermined significance, recent deep vein thrombosis started on Rivoroxaban, recent rectal bleeding. Spoke to who is of the opinion that the Rivaroxaban most likely played a part in the bleed/death. He will liaise with his Consultant (F) as to who will complete the Coroner's report. Decision taken for Consultant to complete circumstances of death with CoD.

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Report details

Reference: 2022-0280
Date of report: 7 September 2022
Coroner: Paul Cooper
Coroner area: Lincolnshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 30 Nov 2022 (estimated).

Sent to

United Lincolnshire Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.