Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0485, written 20 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Nov 2023 |
|---|---|
| Reference | 2023-0485 |
| Deceased | Susan Gladstone |
| Coroner | Graham Danbury |
| Coroner area | Hertfordshire |
| Category | Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
CORONER’S OFFICE
AREA OF HERTFORDSHIRE
Date: 20 November 2023
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: XXX
1. CORONER
I am Graham Danbury Assistant Coroner for Hertfordshire
2. CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
4. INVESTIGATION AND INQUEST
On 11 January 2021 I commenced an investigation into the death of Susan Ann GLADSTONE.
The investigation concluded at the end of the inquest on 20 November 2023.
The conclusion of the inquest was She died as a result of a generally unknown interaction
between warfarin and tramadol which caused exceptional thinning of her blood
1a Intraparenchymal and Subarachnoid Haemorrhage
1b
1c
II
5. CIRCUMSTANCES OF DEATH
Mrs Gladstone was admitted to Lister Hospital on 06/01/2021 presenting with a history of feeling
increasingly unwell over the preceding few days. On admission Mrs Gladstone was found to have
pyelonephritis and was treated with IV antibiotics. Mrs Gladstone was on warfarin, and had
recently been prescribed tramadol. Her INR was found to be extremely elevated at 11.6. Reversal
medication was prescribed. Mrs Gladstone's condition deteriorated and she died at 22.58 hrs on
08/01/2021
6. CORONERS CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is
my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
(1) Mrs Gladstone had been prescribed warfarin for a number of years and her levels were
regularly checked by the Anticoagulation Service. On 20th December 2020 Mrs Gladstone was
prescribed tramadol for low back pain, with a further prescription on 4th January 2021.
(2) On 21st December 2020 her International Normalised Ratio [INR] was found to be 3.3. When
she was admitted to Lister Hospital on 6th January 2021 tests showed her INR to be 11.6.
Immediate action to reverse this was taken. The evidence showed that this level of blood thinning
was likely to cause significant bleeding including in the brain. The cause of death was bleeding in
the brain
(3) A comment from the Anticoagulation Service in relation to tramadol reads "Known interactor
although this is not listed in the BNF, from experience we have seen that this can increase the
INR." There was nothing to warn the prescribing doctor of any possible interaction.(4) I found on
the balance of probabilities that an interaction between tramadol and warfarin had caused this
dangerous, and in the event fatal, INR level to develop.
7. ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you, NHS England
have the power to take such action.
8. YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
06/02/2024. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
9. COPIES AND PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons,
10. I am also under a duty to send the Chief Coroner a copy of your response.
.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may
send a copy of this report to any person who he believes may find it useful or of interest. You may
make representations to me, the coroner, at the time of your response, about the release or the
publication of your response by the Chief Coroner.
11. 20 November 2023
Signature
Mr. Graham Danbury
Assistant Coroner for Hertfordshire
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