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War veteran’s death fall linked to drug mix-up
Inquest told request for patient to be monitored was not acted on
A WAR hero bled to death after a fall because medical staff failed to monitor his blood-thinning drug, an inquest heard on Tuesday.
St Pancras coroner Dr Andrew Reid is to ask senior health officials to carry out further investigations after a communication failure between medical staff led to the death of Thomas Martin, 84, after a fall at his Clerkenwell home in December last year.
Mr Martin, a retired stationery store manager from Sage Way, was receiving blood-thinning drug warfarin after suffering a clot in his lung. An autopsy showed the warfarin in his body had risen to a dangerously high level.
Mr Martin’s blood was supposed to be monitored closely but was left unchecked for a month because a request from doctors at University College London Hospital (UCLH) for GPs and nurses to monitor him was not followed up.
UCLH consultant physician Dr Adrian Wagg said the hospital had written to Mr Martin’s GP, Dr Taik Chua, to request he monitor his blood but this was never acted upon.
He said he referred Mr Martin to Dr Chua “purely because of his frailty”, but that the GP never contacted the hospital to say he could not check Mr Martin’s blood.
When asked what he thought the hospital’s letter was referring to, Dr Chua said: “I would assume that was an anti-coagulation clinic at UCLH because we don’t run an anti-coagulation clinic at all.”
A concerned district nurse did send a blood sample to UCLH’s anti-coagulation unit but it was unable to accept it because Mr Martin was not registered with them.
Camden Primary Care Trust’s Alison Kett, who is in charge of the borough’s district nurses, told the court she had investigated the case.
She claimed district nurses had phoned and faxed the GP to request Mr Martin be referred to the unit but again this was not acted upon.
Coroner Dr Reid, who recorded a narrative verdict, said: “The only conclusion I can reach is that Mr Martin died as a result of a recurrent accidental fall to which confusion, miscommunication, misunderstanding and loss to the anti-coagulation follow-up contributed.”
He added: “I’m concerned the problems in this case might arise in another case. I’m going to write to the appropriate authorities to report the facts so they can investigate further and perhaps make changes to prevent further fatalities from taking place.”
Mr Martin’s stepson, Dave Harries, said after the hearing: “It’s basically what I was hoping to hear. There were many shortcomings and a lack of communication between departments.”
He said his stepfather, who received a mention in dispatches after fighting in the Battle of Monte Cassino in 1944, had hoped as a young man to play cricket for England, adding: “He reckoned his cricketing career was ended by the war.”
Mr Harries said his stepfather retired early to look after his wife Eva after she was diagnosed with multiple sclerosis.
He added: “He was a good, forthright man who cared for my mother in her later years. He adored her. They were blissfully happy. After my mother’s death, he missed her dearly.”
A UCLH spokesman said: “Mr Martin was treated by the geriatric team at UCLH following a fall in October, 2006. Requests were made by doctors at UCLH for the levels of warfarin in Mr Martin’s body to be monitored by his GP and district nurses on his return to the community. At no point was UCLH given any indication that this request had not been acted on.
“Mr Martin was admitted to University College Hospital in December 2006 following another fall. It then became apparent that this monitoring had not been done. The trust is working with Camden PCT, which commissions care for patients in the community, to try to ensure this sort of breakdown in communication does not happen again.
“UCLH has received no complaint from Mr Martin’s family about his treatment here.” |
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