Mary James

On the 22nd May 2015, I commenced an investigation into the death of Mrs. Mary Patricia James, 80 years old. The investigation concluded at the end of the inquest on the 21st August, 2015. The conclusion of the inquest was ‘Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing’.

Mrs. Mary James had previously received a prosthetic heart valve for which anti-coagulation therapy was required. Monitoring and dosing her anticoagulation therapy was undertaken by the Royal Gwent Hospital (RGH) with the Care Home providing blood samples for analyses.

Between the period 16th October 2014 and May 2015 only one blood sample was sent for analysis by the Care Home of its resident Mrs. James which was dated 11.03.15. This sample was incorrectly labelled by staff at the Home therefore the analysis could not be undertaken. From the evidence heard at Inquest there was a failure to discuss the difficulty of obtaining blood samples from Mrs. James with her family,

(GP) and the INR Unit at RGH. There was no training provided to the member of staff responsible for failing to comply with requirements for the labelling of blood samples for INR testing.

Letters were sent from the INR Unit to the Care Home dated 27.10.14; 25.11.14; an undated 3rd letter advising of the failure to send blood samples for INR monitoring and 08.05.15 confirming discontinuation of INR monitoring. The letters dated 25.11.14 and the undated letter were copied to the GP Surgery with a further letter sent to the GP dated 07.04.15. However, neither party responded to these letters. This did not raise any concern or prompt any action by Dr. Turner although she confirmed that such a letter had arrived in her ‘drop box’. However, she had noted the INR Unit’s letter advising of the lack of INR monitoring had been sent originally to Mrs. James’ previous GP’s practice. Dr. Turner did not correct this error or ensure a member of her Practice informed the INR Unit of Mrs. James’ transfer to the Bryntiron Street Surgery thereby permitting the error to be perpetuated.

The GP further stated that only one letter had arrived in her drop box so she assumed any other correspondence must have gone to the drop box of her colleagues who it appeared had similarly failed to respond.

The Care Home Manager at Inquest confirmed that Mrs. Mary Patricia James was most likely receiving her Warfarin tablets as they were being reordered at appropriate time intervals however, he could not be certain from the records maintained. However, at times she refused her medication and it was not clear whether or not that included Warfarin.

in the area of:

 Ensuring communications from the INR Unit are responded to by institutions responsible for the care of an individual requiring anticoagulation therapy.  Ensuring communications from the INR Unit to the GP are responded to including new patient transfers.  Ensuring training is provided by the Care Home to those with responsibility for labelling of bloods for INR monitoring.  Compliance with keeping reliable medical records for prescription and ingestion of anticoagulation therapy and incidence of medication non compliance .  In the event a patient declines anticoagulation medication or blood sampling, to ensure such non-compliance is reported to the GP and the INR Unit for appropriate management.  Ensuring a process is put into place within the Bryntirion Surgery to recognise and act on a patient’s failure to undergo INR monitoring when the Surgery is issuing repeat prescriptions of anticoagulation therapy.