On the 5th November 2013 commenced an investigation into the death of Patricia Margaret Thomas who was aged 79 years_. The investigation concluded at the end of inquest on the 2nd March 2016. The conclusion of the inquest was that in relation to the medical cause of death; the deceased died on the 30" October 2013 at Morriston Hospital, Swansea from: la) an intracerebral haemorrhage II Warfarin Treatment for Atrial Fibrillation, Miconazole Treatment of Oral Thrush recorded a narrative conclusion as follows That the deceased died an intracerebral haemorrhage the effects of which may have been contributed to by the combined use of Warfarin and Miconazole gel medications_

Mrs Margaret Patricia Thomas was found violently thrashing around in her bed by her husband at around 4.OOam on the 30th October 2013. She was unresponsive and appeared to have left sided weakness She was conveyed to Morriston Hospital A & E Department where she underwent blood tests and a CT scan: She was diagnosed as having suffered an intracerebral bleed causing a midline shift of the brain. No surgical intervention was recommended. Instead Mrs Thomas was made comfortable and she passed away just after 12.OOpm that day: She had atrial fibrillation for which she took Warfarin: Some two weeks prior to her death she had presented to her NHS dentist complaining of symptoms consistent with oral thrush; She was prescribed Miconazole Gel by the dentist and this was dispensed in the form of Daktarin Gel by the local pharmacy: She was having regular INR checks and on admission it was noted to be greater than 10 Her usual range was_between 2 and 3 the the from

CoRONERS CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows_ It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding: (2) There is a significant lack of knowledge of the interaction among health professionals andlor (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.