Warfarin patient dies from brain bleed after GPs fail to run 'fundamental' test

An elderly woman died of a brain bleed after her GP clinic failed to run an important test for more than a year, a coroner has found.

Neomai Moa Akauola,​ 83, died at Auckland City Hospital​ on September 23, 2021.

The Ōtāhuhu retiree had a number of long-standing health conditions and had been on warfarin, a blood thinner, since 2016.

However, she was “independent, self-caring and active for her age”, a report by Coroner Alison Mills​ showed.

In August 2021, Akauola’s health began to deteriorate. She experienced back pain, nausea, vomiting and loss of energy.

On September 10, Akauola’s daughter had a phone consultation with her mother’s GP.

The GP reviewed Akauola’s medical notes and found she had not had an international normalised ratio (INR)​ test since April 2020 – nearly 18 months prior.

INR tests, which measure the amount of time it takes for blood to clot, are important tests for those on warfarin.

According to the coroner’s medical adviser, they should be performed about once a month.

Akauola was admitted to hospital that day and it was discovered she had a number of irreversible brain bleeds. She died 13 days later.

Coroner Mills said records from Akauola’s GP, Langimalie Clinic,​ showed her INR had been “generally checked on a monthly basis” up until April 2020.

However, in that month, there was a “serious breakdown in the communication” between staff, Akauola and her caregivers, resulting in Akauola continuing to take warfarin without her INR being monitored, the clinic said.

It did not provide any explanation for the “breakdown in communication”.

The coroner noted three health professionals at the clinic continued to prescribe warfarin for Akauola, despite not ordering the tests.

“In [the medical adviser’s] opinion this clearly fell below accepted practice and was likely to have contributed to Mrs Akauola’s death.”

She also noted the optimal INR range for Akauola was between 2.0 and 3.0. When she died, she had an INR above 10 – a number associated with a high risk of bleeding.

Coroner Mills said the clinic’s failure to run the tests was “very concerning”, as they were a “fundamental aspect” of prescribing warfarin.

In response, Langimalie said it had created an INR patient register and updated the computer system that managed patients.

Any patients overdue for INR tests would now be highlighted in red, it said.

The practice had also appointed an “INR champion”, whose job included checking the register weekly and contacting patients who were overdue for their tests.

In light of those changes, Coroner Mills did not consider it necessary to make any recommendations to the clinic.

However, she said she wished to encourage all GPs to review the way they managed warfarin patients, “given the serious consequences of failing to monitor INR”.

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