Fiaz Siddique concludes a 2-day inquest representing the family of the deceased, a Mrs X.
Fiaz SiddiqueThe inquest into the death of X, who died after suffering from a significant right sided Subdural Haematoma whilst admitted into hospital, found that there were missed opportunities to have identified the high INR (International Normalised Ratio – this is an indicator of the ability and rate of blot clotting) sooner and to have commenced treatment sooner to reverse the high INR. Therefore, in the Coroner’s findings, whilst the cause of the bleeding was not ascertained, the delay in giving anticoagulation may have contributed to and may have caused death. These findings were in accordance with the trust’s own investigations.
By way of background, X had been admitted to Calderdale Royal Hospital on 23 January 2022 with a presentation suspicious of a suspected stroke. However, CT scans and an MRI scan did not support this. Her medical history taken on admission noted reference to a Pulmonary Embolus in 2015, following which she had been prescribed Warfarin (a blood thinner). As part of her care on admission to hospital, a sample of blood was obtained for analysis. The sample was underfilled such that her INR was not capable of being recorded. This failure to test the INR was not reported verbally by the lab to the doctor who had obtained the blood sample but rather the results were posted onto a system with the expectation that the doctor would review it himself. However, this was not done and went unnoticed. There was a delay in obtaining a further blood sample for analysis until 25 January 2022. That sample was reported with an INR of 6.6, increasing the risk factors for bleeding. This was outside of X’s INR target range which was 2-3.
Given the doctors ought to have been aware of the urgent need to reverse the high INR, there was a delay in prescribing Vitamin K, an anticoagulant used the reserve the high INR, in the order of two hours after the doctors became aware of it. X was eventually prescribed such Vitamin K intravenously, however, the Coroner found that the treatment ought to have been administered shortly after it was prescribed or by the tea-time round. However, that dose was inexplicably not administered for some 7 ½ hours after being prescribed. The trust was unable to proffer any reason for the delay in its administration.
Unfortunately, in the early hours of 26 January 2022, some 3 ½ hours after being given Vitamin K, X was found unresponsive by nursing staff with a Glasgow Coma Scale of 3, indicating a detrimental level of consciousness. Investigations identified she had suffered a significant right sided Subdural Haematoma, a significant bleed of the brain. This was not amenable to surgical intervention and was unsurvivable. X was placed on end-of-life care and her death was confirmed on 4 February 2022 at 9:20 hours.
The trust has made a number of changes to avoid such mistakes from happening again including the installation of a Point-of-Care blood test for critically unwell patients requiring an INR test with immediate results.
Contact Fiaz’s clerks
Madeleine Gray on 0113 202 8603