Annie Lloyd
PFD Report
Partially Responded
Ref: 2019-0493
Coroner's Concerns (AI summary)
Inadequate processes for checking warfarin dosage resulted in GPs prescribing medication based on copied records and relying on family input, without direct verification of the correct dosage.
View full coroner's concerns
1. Evidence emerged during the inquest that there was an inadequate process in place for checking the patient’s warfarin level dosage. It appears that a “yellow book” confirming the dosage was being copied and the GP issued the prescription without checking this.
2. The GP practice claim to have placed reliance on the family to confirm the dosage required.
2. The GP practice claim to have placed reliance on the family to confirm the dosage required.
Responses
Action Taken
Brace Street Health Centre has implemented several changes, including informing Warfarin patients to bring their yellow books to appointments, scanning the books, coding the INR, and implementing a written Warfarin prescribing procedure. They have also undertaken safe prescribing audits and death review audits. (AI summary)
Brace Street Health Centre has implemented several changes, including informing Warfarin patients to bring their yellow books to appointments, scanning the books, coding the INR, and implementing a written Warfarin prescribing procedure. They have also undertaken safe prescribing audits and death review audits. (AI summary)
View full response
Dear Mr Zafar, RE: Mrs Annie Lloyd can confirm that these are the improvements that we have implemented to prevent future deaths from occurring:
1. All of our patients (who take Warfarin) have been told that must bring in their yellow Warfarin book every time g0 to have their INR checked at the hospital: The Warfarin book will be scanned and then given to the practice manager who will code the latest INR. She will then enter on to their consultation the date the INR was taken, the result, what dose of medication should be and when their next INR is She will then request the correct strength as per the vellow Warfarin book: The General Practitioner will also check the details before issuing the prescription. 2 We have recently undertaken safe prescribing audits on NSAIDs, Valproates and Lithium_
3. The Practice now has a written Procedure for the process of prescribing Warfarin, checking INR results and altering doses. Please find this document attached, thev they they taking due:
4 We have recently undertaken death review audit so that we can look at the causes of a death and the factors that contributed to it If there are any actions that could prevent future deaths we will put them into practice. 5, Our CCG pharmacist is undertaking Pincer audit regularly to ensure the safety of patients Warfarin: He runs search on the practice computer and prints out a list of patients, if any, who have not had their INR checked recently and gives it to the practice manager: She will then telephone the patient and ask them to bring in their yellow Warfarin book;
6. We have already prevented future problems from happening on two occasions: Date of incident: August 2019 letter from the Cardiologist was received at the practice stating that one of our patients needed to be put on Warfarin: Itelephoned the patient and was told that he had been to the Warfarin clinic and had been started on Warfarin already: was unaware of this as we had not received a letter from the Warfarin clinic informing us of this palso noticed that the patient was prescribed Diclofenac last vear when he was not Warfarin. The patient stated that the Warfarin clinic did not tell him not to take NSAID. warned him that he must not take any Diclofenac, Ibuprofen, Naproxen while he is on Warfarin. also contacted the anticoagulation nurse at the Warfarin clinic who told him that the patient had been seen by them and started Warfarin and letter had been sent to the practice but we did not receive it. also told her that must tell all patients to take their yellow Warfarin book to their General Practitioner. Date of incident: 30th August 2019 The practice manager noticed that one of our patients had been to the Warfarin clinic twice and had his INR checked but had not brought in the yellow Warfarin book to show US. The practice manager also noticed that he had not reduced the dose of Warfarin as per the yellow book taking 30th taking on they
telephoned the Warfarin clinic and told them he had been taking daily continually instead of reducing this to 5.75mgs daily- advised the patient to continue to take 6mgs and for him to have his INR done sooner than planned. The practice manager informed the patient that he must bring in his yellow Warfarin book time he attends the Warfarin clinic so we can have up to date INR readings The patient was also advised that he must follow the Warfarin clinic instructions when told to lower or higher the dose. 7 Further actions we have taken; The receptionist will photocopy and scan the yellow book immediately and then give it to the practice manager who will code the latest INR and check the correct dose: The GP will then check it again. Our pharmacist is quarterly audit to make sure we are not missing any patients. a) The assistant practice manager will check Warfarin requests when the practice manager is on leave: b) We have involved the CCG who will be sending someone from the Medicines Management Team to support the practice with high risk medication reviews: c) Discussion with Medicines Management team took place on Wednesday December 2019. CCG will undertake a shared care meeting to discuss what happened: We now robust system in place to prevent any further recurrence of future deaths from Warfarin.
1. All of our patients (who take Warfarin) have been told that must bring in their yellow Warfarin book every time g0 to have their INR checked at the hospital: The Warfarin book will be scanned and then given to the practice manager who will code the latest INR. She will then enter on to their consultation the date the INR was taken, the result, what dose of medication should be and when their next INR is She will then request the correct strength as per the vellow Warfarin book: The General Practitioner will also check the details before issuing the prescription. 2 We have recently undertaken safe prescribing audits on NSAIDs, Valproates and Lithium_
3. The Practice now has a written Procedure for the process of prescribing Warfarin, checking INR results and altering doses. Please find this document attached, thev they they taking due:
4 We have recently undertaken death review audit so that we can look at the causes of a death and the factors that contributed to it If there are any actions that could prevent future deaths we will put them into practice. 5, Our CCG pharmacist is undertaking Pincer audit regularly to ensure the safety of patients Warfarin: He runs search on the practice computer and prints out a list of patients, if any, who have not had their INR checked recently and gives it to the practice manager: She will then telephone the patient and ask them to bring in their yellow Warfarin book;
6. We have already prevented future problems from happening on two occasions: Date of incident: August 2019 letter from the Cardiologist was received at the practice stating that one of our patients needed to be put on Warfarin: Itelephoned the patient and was told that he had been to the Warfarin clinic and had been started on Warfarin already: was unaware of this as we had not received a letter from the Warfarin clinic informing us of this palso noticed that the patient was prescribed Diclofenac last vear when he was not Warfarin. The patient stated that the Warfarin clinic did not tell him not to take NSAID. warned him that he must not take any Diclofenac, Ibuprofen, Naproxen while he is on Warfarin. also contacted the anticoagulation nurse at the Warfarin clinic who told him that the patient had been seen by them and started Warfarin and letter had been sent to the practice but we did not receive it. also told her that must tell all patients to take their yellow Warfarin book to their General Practitioner. Date of incident: 30th August 2019 The practice manager noticed that one of our patients had been to the Warfarin clinic twice and had his INR checked but had not brought in the yellow Warfarin book to show US. The practice manager also noticed that he had not reduced the dose of Warfarin as per the yellow book taking 30th taking on they
telephoned the Warfarin clinic and told them he had been taking daily continually instead of reducing this to 5.75mgs daily- advised the patient to continue to take 6mgs and for him to have his INR done sooner than planned. The practice manager informed the patient that he must bring in his yellow Warfarin book time he attends the Warfarin clinic so we can have up to date INR readings The patient was also advised that he must follow the Warfarin clinic instructions when told to lower or higher the dose. 7 Further actions we have taken; The receptionist will photocopy and scan the yellow book immediately and then give it to the practice manager who will code the latest INR and check the correct dose: The GP will then check it again. Our pharmacist is quarterly audit to make sure we are not missing any patients. a) The assistant practice manager will check Warfarin requests when the practice manager is on leave: b) We have involved the CCG who will be sending someone from the Medicines Management Team to support the practice with high risk medication reviews: c) Discussion with Medicines Management team took place on Wednesday December 2019. CCG will undertake a shared care meeting to discuss what happened: We now robust system in place to prevent any further recurrence of future deaths from Warfarin.
Sent To
- Brace Street Health Centre
- Care Quality Commission
Response Status
Linked responses
1 of 2
56-Day Deadline
26 Dec 2019
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 15 April 2019, I commenced an investigation into the death of Mrs Annie Lloyd. The investigation concluded at the end of the inquest on 19 September 2019. The conclusion of the inquest was a short narrative conclusion of:
Mrs Lloyd was on anti-coagulation medication of warfarin. She was initially on a level of 2.5mg. This was increased by the General Practitioner on the 4 March 2019 to 3mg. She continued to take an additional dosage of 2mg giving a total of 5mg for around 15 days. On the 6 April 2019 she was found unresponsive and admitted to hospital after developing a subdural haematoma. It is not clear on the evidence if the increased dosage of warfarin gave rise to the bleed or that it was a spontaneous bleed or alternatively involved a minor traumatic event.
The cause of death was:
1a Raised Intracranial Pressure b Sub Dural Haematoma
Mrs Lloyd was on anti-coagulation medication of warfarin. She was initially on a level of 2.5mg. This was increased by the General Practitioner on the 4 March 2019 to 3mg. She continued to take an additional dosage of 2mg giving a total of 5mg for around 15 days. On the 6 April 2019 she was found unresponsive and admitted to hospital after developing a subdural haematoma. It is not clear on the evidence if the increased dosage of warfarin gave rise to the bleed or that it was a spontaneous bleed or alternatively involved a minor traumatic event.
The cause of death was:
1a Raised Intracranial Pressure b Sub Dural Haematoma
Circumstances of the Death
i) Mrs Lloyd was on warfarin medication and had a medical history including atrial fibrillation. ii) She would attend the anti-coagulation clinic at Hospital and her last attendance at the clinic on the 7 March 2019 confirmed she was on 2.5mg per day. She would normally take two brown tablets (1mg) and one white tablet (0.5mg) giving a total of 2.5mg. iii) On the 4 March 2019, a prescription for 3mg warfarin was issued by her GP, The GP has suggested that they were informed by family members that she now required a dosage of 3mg. iv) From the evidence it appears that she was then taking one blue tablet (3mg) and two brown tablets giving a dosage of 5 mg over a period of around two
[IL1: PROTECT] weeks. v) Mrs Lloyd started to experience chest pain and they went back to the surgery to see the GP on the 1 April 2019. The family told the GP that she had taken 5mg and the GP understood this to mean she had taken a single “one-off” dosage and reduced the dosage to 2mg for a week and then for her to recommence at 2.5mg vi) Evidence from a Consultant Haematologist confirmed warfarin is used as anticoagulation to prevent strokes and treat atrial fibrillation. The increased warfarin may have caused a bleed or expansion of a bleed caused by another event and we cannot rule out a mild trauma event; although there was no clear evidence of a traumatic injury. vii) On the 6 April 2019, Mrs Lloyd was found at her home unconscious. On arrival at New Cross Hospital she was deeply comatose. A CT Scan of her head revealed a large subdural haematoma with raised intracranial pressure. Sadly, her condition declined rapidly, and she passed away the same day.
[IL1: PROTECT] weeks. v) Mrs Lloyd started to experience chest pain and they went back to the surgery to see the GP on the 1 April 2019. The family told the GP that she had taken 5mg and the GP understood this to mean she had taken a single “one-off” dosage and reduced the dosage to 2mg for a week and then for her to recommence at 2.5mg vi) Evidence from a Consultant Haematologist confirmed warfarin is used as anticoagulation to prevent strokes and treat atrial fibrillation. The increased warfarin may have caused a bleed or expansion of a bleed caused by another event and we cannot rule out a mild trauma event; although there was no clear evidence of a traumatic injury. vii) On the 6 April 2019, Mrs Lloyd was found at her home unconscious. On arrival at New Cross Hospital she was deeply comatose. A CT Scan of her head revealed a large subdural haematoma with raised intracranial pressure. Sadly, her condition declined rapidly, and she passed away the same day.
Action Should Be Taken
1. The GP Practice may wish may wish to review its processes in place in general when dealing with prescriptions including repeat prescriptions. More specifically, they may wish to review the process in place when changing a dosage of warfarin.
2. The CQC may wish to further review the GP Practice and consider whether further inspections are necessary.
[IL1: PROTECT]
2. The CQC may wish to further review the GP Practice and consider whether further inspections are necessary.
[IL1: PROTECT]
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.