A bereaved family has been awarded damages following admissions of liability from two NHS trusts after they failed to monitor and maintain appropriate anti-coagulation levels in a warfarin-dependent patient.
Mrs P had an underlying history of ischaemic heart disease and atrial fibrillation. She had a double prosthetic aortic valve and a pacemaker, and was required to take warfarin and monitor her international normalised ratio (INR) daily to ensure that her blood coagulation was within therapeutic range.
Mrs P had been admitted to Seward Lodge, a mental health unit of Hertfordshire Partnership University (HPU) NHS Foundation Trust, due to a deterioration in her depression and bipolar effective disorder which had rendered her catatonic. She was sectioned and commenced on lithium treatment. On account of her poor mental state, Mrs P had poor food and fluid intake and was often non-compliant with medication. Despite this being frequently documented by staff, the clinical significance of her warfarin was not recognised and alternative routes of administration (ie by way of injection) were not considered.
During her admission she was transferred on numerous occasions to Lister Hospital for clinical care associated with a suspected lower respiratory tract infection, lithium toxicity and dehydration. Within a four-week period, Mrs P’s INR was measured on nine occasions. Her INR was below therapeutic range on seven out of the nine occasions but no action was taken to adjust her warfarin dose and ensure effective administration.
Mrs P’s clinical condition deteriorated further to the extent that she became extremely drowsy and unresponsive. She was transferred back to Lister Hospital for a CT brain scan which demonstrated a focal aneurysm indicative of a right hemisphere stroke. Mrs P remained in a reduced state of consciousness and suffered paralysis down the right side of her body. She began to exhibit signs of seizure activity. She was unable to swallow and required a feeding tube into her stomach.
Mrs P suffered a further stroke two months later in the right cerebellar with likely brain stem involvement and was placed on end-of-life care. She was in a deep coma and sadly passed away a week later.
Following the diagnosis of Mrs P’s initial stroke, HPU NHS Foundation Trust performed an internal investigation which highlighted concerns in respect of the lack of specialist input from the anticoagulation clinic or haematology service regarding her missed warfarin doses and out-of-range INR results.
The clinical negligence team at Penningtons Manches Cooper was instructed to act on behalf of the family in light of the investigation findings. Following receipt of medical expert evidence, a pre-action protocol letter of claim was prepared highlighting the failures of both NHS trusts to administer life-saving anticoagulant medication during a four-week period.
In addition, the letter of claim highlighted the failure to recognise and manage Mrs P’s subtherapeutic INR results, both of which ultimately led to Mrs P suffering a stroke and her untimely death.
A letter of response was served on behalf of both NHS trusts. Ultimately, the allegations of negligence were admitted in full, and an apology was made to the family expressing the trusts’ sincere regret for the shortcomings in the care provided to Mrs P.
Further evidence was put to the defendant in respect of quantum and settlement was negotiated without the need to issue and serve court proceedings.