On 13th November 2013 commenced an investigation into the death of Stephen Ellis dob 23rd December 1953. The investigation concluded on the 4th March 2014 and the conclusion was Misadventure. The medical cause of death was Ia Haemopericardium 1b Recent aortic root graft and aortic valve replacement surgery and subsequent warfarinisation 1c Aortic stenosis and aortic root aneurysm 2 Ischaemic and hypertensive heart disease, long term haemo-dialysis due to previous nephrectomies for renal cell carcinoma. CIRCUMSTANCES OF THE DEATH: The deceased was admitted to hospital for the necessary heart surgery and he was acknowledged to be a patient with significant co-morbidities_ After the surgery he was administered warfarin and thereafter there appears to have been some blood oozing from around the grafted area. When he was administered the warfarin whilst in hospital his INR levels were carefully monitored but upon his release from hospital these checks were reduced to 'weekly' and it is apparent that his INR was without this properly noted at the time. The consultant surgeon who performed the operation told me in evidence that warfarin home monitoring kits are readily available and widely used outside the UK: If Mr Ellis had had such a monitoring kit; he may have registered a higher than acceptable INR and this may have been picked up. if S0, it was the view of the surgeon, the outcome might have been different and he could have survived:

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In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. It is essential that full information is passed promptly to the GP practice of a patient being discharged.