Articles and Case Studies

A Coroner’s Cautionary Christmas Tale

15 Nov 2017

coroner's tale

A recent coronial inquest highlighted communication issues between a Cardiologist and a General Practitioner (GP) which resulted in a patient’s death.1

Case history

Mrs Aston, aged 86 years, consulted a Cardiologist regarding her atrial fibrillation on 19 December 2012. He advised her that she should be anticoagulated and commenced her on warfarin 5mg daily. The Cardiologist impressed upon Mrs Aston the need for monitoring of the warfarin level and asked her to have a blood test two days later on 21 December. He also advised her to see her GP that day.

The Cardiologist did not arrange for a copy of the INR result of 21 December to be sent to Mrs Aston’s GP. The Cardiologist provided Mrs Aston with a note which stated: Atrial fibrillation – warfarin rat poison. Mrs Aston’s INR result on 21 December was 1.9 and the Cardiologist did not take any particular action with regards to this result.

The Cardiologist dictated a letter to Mrs Aston’s GP advising him that Mrs Aston had been commenced on warfarin. The letter went on to be typed and did not reach the GP until 9 January 2013.

For reasons which are not clear, Mrs Aston did not contact her GP on or around 21 December. It was not until 3 January 2013 (15 days after commencing warfarin) that she contacted her GP because she was not feeling well, and there was blood in her urine.

Mrs Aston’s GP visited her at home on the evening of Thursday 3 January. He was surprised to learn that she had been commenced on warfarin. He advised her to cease taking warfarin for the moment, and he also prescribed antibiotics as he suspected she may have a urinary tract infection. He wanted to test her INR, but decided to return the following day to do this.

The blood sample taken the next day was deemed inadequate to be tested. The request form did not mark the sample as urgent and the GP did not follow up the missing result until Monday.

On Saturday 5 January, Mrs Aston’s son found her slumped in a chair. She was taken to hospital but died a short time later. Cause of death was subdural haematoma, and her INR was 12.


In this case, a robust and foolproof handover was needed to ensure monitoring of Ms Aston’s INR. The Cardiologist agreed he was aware that the GP would not receive his letter for 10-14 days. Handover of care to her GP had been delegated almost entirely to Mrs Aston. For whatever reason, Mrs Aston did not understand the importance of the monitoring or seeing her GP within a few days.

It was the Coroner’s view that Mrs Aston’s death could have been prevented if her warfarin had been appropriately monitored between 19 December 2012 and 3 January 2013. He was critical of both the Cardiologist and the GP.

Medico-legal issues

The Cardiologist’s handover was grossly inadequate, relying as it did on Mrs Aston alone. The Cardiologist should have taken other steps (phone call, fax, email) to inform Mrs Aston’s GP that she had been started on warfarin and that he was responsible for monitoring. He did not copy the GP into the INR test of 21 December.

The GP’s management was also criticised in that he failed to arrange an INR test as a matter of urgency when he became aware that Mrs Aston had not been having her INR monitored.

This case highlights that handover of care is a critical time for patients, especially with potential delays during the Christmas period.

Dr Jane Deacon
Medico-legal Adviser, MDA National


  1. Inquest into the Death of Ms Marjorie Aston. Available at:
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