Susan Gladstone
PFD Report
Historic (No Identified Response)
Ref: 2023-0485
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
15 Jan 2024
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroners Concerns
(1) Mrs Gladstone had been prescribed warfarin for a number of years and her levels were regularly checked by the Anticoagulation Service. On 20th December 2020 Mrs Gladstone was prescribed tramadol for low back pain, with a further prescription on 4th January 2021.
(2) On 21st December 2020 her International Normalised Ratio [INR] was found to be 3.3. When she was admitted to Lister Hospital on 6th January 2021 tests showed her INR to be 11.6. Immediate action to reverse this was taken. The evidence showed that this level of blood thinning was likely to cause significant bleeding including in the brain. The cause of death was bleeding in the brain (3) A comment from the Anticoagulation Service in relation to tramadol reads "Known interactor although this is not listed in the BNF, from experience we have seen that this can increase the INR." There was nothing to warn the prescribing doctor of any possible interaction.(4) I found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event fatal, INR level to develop.
(2) On 21st December 2020 her International Normalised Ratio [INR] was found to be 3.3. When she was admitted to Lister Hospital on 6th January 2021 tests showed her INR to be 11.6. Immediate action to reverse this was taken. The evidence showed that this level of blood thinning was likely to cause significant bleeding including in the brain. The cause of death was bleeding in the brain (3) A comment from the Anticoagulation Service in relation to tramadol reads "Known interactor although this is not listed in the BNF, from experience we have seen that this can increase the INR." There was nothing to warn the prescribing doctor of any possible interaction.(4) I found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event fatal, INR level to develop.
Report Sections
Investigation and Inquest
On 11 January 2021 I commenced an investigation into the death of Susan Ann GLADSTONE. The investigation concluded at the end of the inquest on 20 November 2023. The conclusion of the inquest was She died as a result of a generally unknown interaction between warfarin and tramadol which caused exceptional thinning of her blood 1a Intraparenchymal and Subarachnoid Haemorrhage 1b 1c
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.