Two doctors could have prevented the death of an Adelaide woman who was prescribed common blood-thinning drug warfarin, an inquest has heard.
Marjorie Irene Aston, 86, died in January 2013 after falling and hitting her head at her Woodville South home.
The inquest was told a few weeks earlier her cardiologist Professor John Horowitz had prescribed warfarin for an irregular heartbeat.
But he only informed Mrs Aston’s GP, Dr Fong Liew, in writing, and the letter did not arrive until after Mrs Aston’s death.
Expert GP Dr Peter Joyner told the court the death could have been prevented with better management by the doctors.
He said people on warfarin required almost daily blood tests, but that did not happen.
Dr Joyner said the cardiologist should have rung Mrs Aston’s GP rather than just sending a letter.
“Mrs Aston did not have any reason not to be prescribed warfarin,” he said.
“The concern arises whereby he was essentially relying on Mrs Aston to be the person who would be organising her follow up.
“When you initiate people you are expected to do an INR [International Normalised Ratio test] every day or every second day. He should have initiated a simple phone call.”
Dr Joyner said people over the age of 80 were at most risk from side effects, such as bleeding, while on warfarin.
The court previously heard before Mrs Aston’s death her blood was far too thin.
Dr Joyner said there was not any urgency to start the patient on warfarin.
He said Professor Horowitz failed to direct a copy of the initial INR test results to the her GP.
“If you order a test you are responsible for managing the results, unless you specifically refer to another doctor,” he said.
Dr Liew only found out about the warfarin prescription weeks later during a home visit to Mrs Aston.
Counsel Assisting the Deputy Coroner Naomi Kereru said Mrs Aston told her GP “the professor has put me on medicine that is making me bleed”.
Patient should have been hospitalised
Ms Kereru said Mrs Aston’s urine by that stage was bloodstained as a result of the unchecked warfarin.
The GP told Mrs Aston to stop taking the drug immediately, but she was not sent to hospital, instead the GP returned the following day to do a blood test.
Dr Joyner said the “gold standard” care would have been to hospitalise Mrs Aston straight away.
“Many doctors would say the sensible thing was to do an INR right then,” he said.
“The gold standard would have been to have an INR at that time.
“I would not necessarily agree with what he did but I can understand his assessment.”
The GP also prescribed Mrs Aston antibiotics for a bladder infection, but Dr Joyner said the GP should have first known the results of an INR test.
“It just brings another risk factor into play,” he said.
“One balance, I would have not given the antibiotic, I would think that I would have encouraged her to get the INR that night.”
The court heard when the GP sent off a blood sample the following day, he did not ask for the results to be provided urgently.
He also failed to follow up the results before the weekend.
Dr Joyner said the death could have been prevented if both doctors had better managed the case and there were checks of her INR levels.
“Reversing warfarin is relatively straight forward, it’s well documented,” he said.
“A fall, a head injury and on warfarin, you should have a head CT.”
He said the case demonstrated how quickly an otherwise healthy individual could deteriorate due to bleeding while on warfarin.
Inquest provides closure to Aston family
The inquest was adjourned until next week when final addresses will be heard.
The victim’s son, Barry Aston, said the inquest was providing some closure.
“Don’t want it to happen to any other family,” Mr Aston said.
“It can’t happen again, it has got to be tidied up, all these loose ends, just got to do the process properly, just cut out any chance of this happening again.”
Mrs Aston’s daughter-in-law, Shirley Aston, said people prescribed warfarin needed better follow-up care.
“The follow up is the critical matter for me,” Ms Aston said.
“It just could have been prevented, it didn’t need to happen.
“She was an incredible lady, she was very, very independent, very stubborn, she knew what she wanted and she was going to do it when she wanted to do it.
“She really trusted her doctor … and that generation tends to, I know my parents are the same.
“She was a lovely lady and this shouldn’t have happened.”