Keith Dimond
22 Oct 2022 · Coroner Sonia Hayes · North East Kent
The coroner's concerns
1. lack of awareness of Iliac Artery Aneurysm diagnosis
“Treating Clinicians stated they were not aware of the diagnosis of Iliac Artery Aneurysm previously made at the Trust in August 2019 even though this was set out in the medical records and made at the same time as the diagnosis of Aortic Abdominal Aneurysm that was known. Abdominal surgery and anticoagulation were undertaken without consideration of this information.”
2. lack of written bleeding risk advice and family communication at discharge
“The patient was discharged on 19 October 2022 with a new diagnosis of Atrial Fibrillation and prescription of Direct Oral Anticoagulant Apixaban was prescribed. The patient was not given any written advice on the risks as to bleeding on this medication and the risks were not shared with family on discharge. This led to advice being sought from 111 and a long delay before 999 was called when the patient deteriorated on 22 October 2022.”
3. failure to follow consultant haematologist advice regarding Beriplex and prophylactic clexane
“Anti-coagulation on readmission was considered complex and the advice of a Consultant [name redacted] was sought but not followed on two occasions: (a) Beriplex and Vitamin K was administered. There was no rationale noted as to why advice to withhold Beriplex was not followed. (b) There was no record as to why advice to give prophylactic clexane was not administered.”