On the 30th October 2008, the team represented a family at a Coroner's Court Inquest. The case was interesting in that the death had not been reported by the hospital as "unnatural" to the Coroner.
The deceased's family became suspicious about the circumstances surrounding the prescription of antibiotics to the deceased in the weeks before her death and so contacted the Coroner's office.
On investigating the matter, we established that antibiotics prescribed by her GP to treat a chest infection interacted with the blood thinning medication Warfarin. The deceased's levels (the ratio of the time taken for the patient's blood to clot compared with a normal person) was, at the time of her admission to hospital, 11.9 whereas the normal INR is between 2 and 3.5. The Coroner was told that this increase in INR had triggered a fatal brain haemorrhage.
At the Inquest, it was established that there were gaps in communications between General Practitioners and Warfarin Clinics and that this had contributed to the deceased's death.
The Hospital Physician, in retrospect, accepted that the deceased's death was not due to "natural" causes.
As a result, the Cork City Coroner, Dr. Myra Cullinane returned a verdict of medical misadventure. She ordered the Death Certificate to record the cause of death as bilateral subdural haemorrhage with a subarachnoid extension due to the elevated INR levels due to drug interaction between Warfarin and antibiotic therapies. She made a recommendation that communications between Warfarin Clinics and General Practitioners be reviewed.
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