On 11 July 2014, commenced an investigation into the death of Phyllis Kerry, DoB 8 June 1935_ The investigation concluded at the end of the inquest on 22 October 2014. The conclusion of the inquest was that the cause of death was 1a Primary intracerebral haemorrhage 1b Warfarin Treatment 1c Metallic aortic valve and aortic root replacement ascending aortic aneurysm 2 Hypertension recorded a narrative conclusion as follows Phyllis died after suffering a stroke, which was complicated by the Warfarin medication she was on.

Mrs had a history of heart valve replacement and aortic aneurysm and was on long-term Warfarin. She was admitted to the ED at Queen's Medical Centre at 1555 hrs on 28"h January 2104, with symptoms suggestive of stroke. She was taken for a CT scan at 1733 The scan showed a bleed consistent with haemorrhagic stroke ED consultant liaised with neurosurgery and haematology colleagues. Neurosurgery advice was that nothing could be done surgically, but that the effects of the Warfarin should be reversed, and should be contacted again if her condition deteriorated . The haematology registrar advised giving Mrs Vitamin K to reverse the Warfarin He did not recommend giving Octaplex He did not discuss the case with his seniors Or with neurosurgery colleagues. It was accepted in evidence that Octaplex should have been given, to reduce the effects of the Warfarin more quickly. Mrs deteriorated, with dropping GCS, and further CT scanning showed that her bleed had increased significantly: After consultation with neurosurgery colleagues, and discussion with her family, DNAR order was put in place and Mrs died her death being confirmed in the early hours of 31 January 2014. The_haematology registrar gave evidence_that he carried out research of his own on 28 To Kerry Kerry Kerry hrs_ The they Kerry Kerry Kerry

January, using Electronic Medicines Compendium, and came to the conclusion that;, because of a risk of clotting; would be better for Mrs to be given Vitamin K instead of Octaplex: took evidence a consultant physician, who said that NICE and RCP guidelines state that both Vitamin K and Octaplex should be given in cases of intracerebral haemorrhage in patients anti-coagulated with Warfarin or similar drugs_ The haematology registrar was not aware of these guidelines, ad the consultant physician told us that there are no current trust guidelines which cover this draft guidelines have been withdrawn but not replaced. Lalso heard that consultant haematologist not involved with this patient; has reviewed the case and advised all haematology and neurosurgery ST doctors that the responsibility for a decision for immediate reversal of Warfarin in patients with CNS bleeds lies with neurosurgery. gave evidence that he does not consider this practice has been adopted that it is simply suggestion and he does not agree that neurosurgery advice is always necessary in cases like this. It is clear that there would need to be involvement from several specialties in relation to prescribing Octaplex in particular. Crucially, however, could not be clear; from the evidence heard, which specialty would ultimately be responsible for deciding when immediate reversal is called for. It was also clear that there was no guideline or protocol in place which the haematology registrar could_have consulted

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: