Source · Prevention of Future Deaths

Marion Prance

Ref: 2019-0154 Date: 15 May 2019 Coroner: Rachel Knight Area: South Wales Central Responses identified: 1 / 1 View PDF

Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced caution.

Date 15 May 2019

56-day deadline 22 Sep 2019 est.

Responses identified 1 of 1

Emergency services related deaths (2019 onwards) Wales prevention of future deaths reports (2019 onwards)

Coroner's concerns

AI summary

Paramedics lacked awareness and training regarding the dangers of administering anticoagulants like Rivaroxaban to elderly fall patients with head injuries, requiring enhanced caution.

View full coroner's concerns

(1) A paramedic with 40 years of experience was unaware of the dangers of administering Rivaroxaban, a blood-thinning medication to an elderly lady who had suffered a fall and banged head; (2) The training of paramedics in relation to the dangers of bleeds in patients who have fallen and are prescribed Rivaroxaban and other similar new style anti-coagulant drugs; (3) The awareness of fast-acting anti-coagulant and the implications of administering them; and (4) The awareness by paramedics that in patients with head injuries following a fall, the true extent of the head injury will not be immediately obvious, and extra caution is required:

Responses

1 respondent

Welsh Ambulance Service NHS Trust NHS / Health Body

21 Jun 2019 PDF

Action Planned

The Trust acknowledged a paramedic's lack of awareness regarding Rivaroxaban and is implementing an action plan for individual learning and organizational changes. They will ensure all clinical staff are aware of the effects of Novel Oral Anti-coagulant drugs. (AI summary)

View full response

Dear Ms Knight Re: The Inquest in relation to Mrs Marian Prance write in response to the Regulation 28 report that you issued to this Trust dated the 15ih May 2019 following the sad death of the late Mrs Marian Prance: In the Report you raised your concerns in relation to four matters_ (1) paramedic with 40 years' experience was unaware ofthe dangers of administering Rivaroxaban; a blood-thinning medication to an elderly lady who had suffered a fall and banged her head; (2) The training of paramedics in relation to the dangers of bleeds in patients who have fallen ad are prescribed Rivaroxaban and other similar new style anti- coagulant drugs; (3) The awareness of fast-acling anti-coagulant and the implications of administering them; and The awareness by paramedics that in patients with head injuries following a fall, the true extent of the head injury will not be Immediately obvious, and extra caution is required, Cadahrddchat Muth Woodlodd Pri WateomCChi{ Extcutve; Jrson KolI Mbet Yaddhadabrth Yn cidatuiu doldbbtd My Gyiino Mut Sautne Tro Trutl Kokonaj Cotoldontmct h Mutt& Enpleh Court drugs

Whilst the Trust acknowledges that during the Inquest you heard verbal evidence from the paramedic who attended Prance, would Ilke to take the opportunlty t0 confirm with you that during 2014 a Clinical Notice number 18 entitled, Novel Oral Anti- coagulant; was published to all clinicians. In that document anti-coagulant therapies including Rivaroxaban were referred to and advice was supplied to staff regarding their use. attach for your reference a copy of that Clinical Notice attach for your reference an action plan that illustrates the actions the Trust will be taking as a direct result of the Regulation 28 Report received from you, this covers both individual learning for Ihe paramedic who provided evidence at the Inquest; as well as arganisational actions t0 ensure that all of our clinical staff are aware of the effects of these Novel Oral Anti-coagulant drugs. would like t0 extend the offer t0 meet with you t0 discuss our response in more detail and to provide you with any further assurances you make require regarding our commitment to continuous improvement:

Report sections

Investigation and inquest

On the 28th February 2018an inquest was opened into the death of Marion Hilda Prance. The investigation concluded on the 13th May 2019_ The conclusion of the inquest was narrative and read as follows: On 24th February 2018 Mrs Prance had an unwitnessed fall at Garth Care Home. In 2016 she had survived a stroke, and was thereafter prescribed Rivaroxaban as an anti-coagulant drug: During the fall; Mrs Prance suffered a head injury and was then given her morning dose of Rivaroxaban on the advice of paramedics. She was subsequently diagnosed as having a subdural haematoma at hospital, and during the day her condition suddenly deteriorated: It became clear that she had suffered a catastrophic brain bleed, which was unsurvivable The administration of the Rivaroxaban may have contributed to the extent of the brain bleed:

Circumstances of the death

Mrs Prance had significant co-morbidities and was prescribed many daily medications She self-managed her type 2 diabetes: She was in Garth Olwg Care Home, but was of full capacity and semi-independently. She accidentally fell over when getting off the commode in her bedroom, and banged her head as well as sustaining a clavicle fracture Care home staff rang for a ambulance which attended promptly at around 7am; Paramedics were concerned that since there may be delays at the Royal Glamorgan Hospital, it would be sensible for Mrs Prance to eat breakfast before took her in. Olwg living living they

Staff at the Care Home asked the paramedics whether they should administer the usual morning medications. Paramedics had sight of the Medication Administration Record for Mrs Prance which included Rivaroxaban, a fast-acting anti-coagulant Notwithstanding the fact that Mrs Prance, 82 had fallen and banged her head, paramedics advised the nursing staff to administer all her usual medications, s0 2s to maintain the status quo, since 'missing medications may cause additional problems to the presenting complaint' Paramedics had an awareness of the dangers of warfarin, and accepted in evidence that in a similar scenario with warfarin, they would have 'held off administering warfarin. They were unconcerned about Rivaroxaban: In evidence, the paramedic said that he had not received any training about the dangers of Rivaroxaban: A subdural haematoma was subsequently diagnosed, and Mrs Prance had developed a catastrophic brain bleed by 6pm the same day: She died the next day: It may be that the Rivaroxaban administered at around 7.30am contributed to the extent of Mrs Prance' $ brain bleed_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and vour organisation have the power to take such action:

Inquest conclusion

On 24th February 2018 Mrs Prance had an unwitnessed fall at Garth Care Home. In 2016 she had survived a stroke, and was thereafter prescribed Rivaroxaban as an anti-coagulant drug: During the fall; Mrs Prance suffered a head injury and was then given her morning dose of Rivaroxaban on the advice of paramedics. She was subsequently diagnosed as having a subdural haematoma at hospital, and during the day her condition suddenly deteriorated: It became clear that she had suffered a catastrophic brain bleed, which was unsurvivable The administration of the Rivaroxaban may have contributed to the extent of the brain bleed:

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Report details

Reference: 2019-0154
Date of report: 15 May 2019
Coroner: Rachel Knight
Coroner area: South Wales Central

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: 22 Sep 2019 (estimated).

Sent to

Welsh Ambulance Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.