A hospital has been criticised in coronial findings after it discontinued warfarin in a patient with a history of unprovoked DVT, discharging him with no bridging anticoagulation and no timely documentation for his GP.
Other identified faults in care of the patient, who had a fatal PE three days after discharge, included a failure by the treating team to consult haematology or gastroenterology despite him having been on lifelong anticoagulation before their decision.
The 76-year-old man had earlier presented to ED at Melbourne’s Sunshine Hospital feeling ‘unwell and weak’. He tested positive for COVID-19 on arrival, which was serious enough to require oxygen therapy, and subsequently displayed haematemesis and hypotension on the ward.
Investigations showed active arterial bleeding from a duodenal ulcer, secondary to H. pylori infection, that was treated with clipping and injection of the bleeding artery.
He also required significant amounts of blood products and administration of clotting factors to reverse the effects of his warfarin therapy, which was ceased to prevent further bleeding, the coronial investigation heard.
Enoxaparin was then prescribed as VTE prophylaxis, but when he was discharged six days later it was with a script for antibiotics to treat the H. pylori, but also a recommendation not to resume his usual warfarin or any other anticoagulation until treatment had been completed and after further discussion with his GP.
The autopsy following his death three days later showed pulmonary thromboemboli in the pulmonary trunk and throughout both lungs as well as DVT was in the right lower leg.
In findings handed down last month, Victorian coroner Katherine Lorenz raised multiple concerns with the care provided, noting consideration from the Coroner’s Prevention Unit that the hospital’s anticoagulation approach was “inappropriate, particularly in the context of a complex condition and the requirement for lifelong anticoagulation”.
“The specialist teams managing him during his admission were best placed to advise him and assist him with recommencing anticoagulation rather than his GP,” she wrote, quoting the unit.
Importantly, the unit’s experts “considered that deeper consideration of anticoagulation on this occasion may have prevented the occurrence of a pulmonary embolism,” she added.
The hospital’s managing body, Western Health, provided a statement defending the care provided, stressing its treating team had delegated recommencing anticoagulation because the GP would have a “holistic understanding” of the patient’s needs.
The GP was better placed to navigate the “potential impact of therapeutic choices on his wellbeing, balancing the risks of thromboembolic disease against the risk of further bleeding”, it said.
In any event, Coroner Lorenz disagreed, finding that the hospital team were “best placed” to recommence anticoagulation.
“Western Health acknowledged that the decision to recommence anticoagulation in this case was a complex decision and should have been referred to gastroenterology and/or haematology for advice,” she added.
“It was not appropriate to assign responsibility for this decision to the GP.”
The lack of communication with the patient’s GP at the time of discharge was another issue identified in the investigation.
The discharge summary was written six weeks after discharge – long after the patient had died in this case – by a doctor not involved in the patient’s care.
It also contained conflicting advice about recommencement of anticoagulation and was addressed to the wrong clinic, the coroner noted.
“The discharge plan documented to withhold warfarin until treatment for H. pylori was completed (seven days) and for the GP to discuss ongoing anticoagulation with a recommendation to change from warfarin to a direct oral anticoagulant (DOAC),” she wrote.
“However, the medications on discharge documented that warfarin was to be withheld for 3 months and then for review by the GP.”
Concluding that the man’s death was preventable, she said clinicians on the treating team “ought to have turned their mind to whether pharmacological VTE prophylaxis was required to continue post discharge and until oral anticoagulation could be resumed or discussed further.”
“Had this occurred, it is very likely that ongoing enoxaparin would have been prescribed post discharge in the context of a patient on pharmacological VTE prophylaxis while therapeutic anticoagulation was interrupted.”
“In turn, this would very likely have prevented development of DVT and subsequent PEs which caused [the patient’s] death.”
She acknowledged that these considerations were not explicitly outlined in local guidelines at the time.
Additionally, Western Health had developed a plan to incorporate advice for this very clinical scenario into their VTE prevention guideline, she said.