Mary James
4 Sept 2015 · Coroner Sarah-Jane Richards · Powys
The coroner's concerns
1. inadequate INR monitoring
“Inadequate monitoring of INR levels in a patient suffering from dementia”
2. uncertain warfarin adherence
“Lack of certainty whether Warfarin was being taken by the patient”
3. communication failure
“Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient's anticoagulation monitoring and the potential need for therapy adjustment”
4. missed hospital admission
“That against this background and the Care Home's concern about a possible ischaemic leg, Mrs [name redacted] was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy”
Responses
No published response was found on judiciary.uk.