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Thomas Martin, as a WWII soldier |
Communication failure led to war hero’s tragic death
A WAR hero bled to death after a fall because medical staff failed to monitor his blood-thinning drugs, an inquest heard last week (Tuesday).
St Pancras coroner Dr Andrew Reid will now write to senior health officials to request further investigations after a communication failure that led to the death of Thomas Martin, 84, in December last year.
Retired stationery store manager Mr Martin, of Sage Way, King’s Cross, who was on blood-thinning drug Warfarin because of a clot in his lung, died after falling at home. A post-mortem examination showed the level of Warfarin in his body had risen from a safe 2.5 to a dangerously high 18.6.
Mr Martin’s blood was supposed to be monitored closely, but was left unchecked for a month because a request from doctors at UCLH for GPs and nurses to monitor him was not acted upon.
UCLH consultant physician Dr Adrian Wagg said the hospital had written to Mr Martin’s GP Dr Taik Chua to request he monitor his blood.
He said he referred Mr Martin to Dr Chua “purely because of his frailty”, but that the GP never contacted the hospital to say he could not check Mr Martin’s blood.
When asked what he thought the hospital’s referral letter was referring to, Dr Chua said: “I would assume that was an anti-coagulation clinic at UCLH because we don’t run an anti-coagulation clinic at all.”
A concerned district nurse did send a blood sample to UCLH’s anti-coagulation unit, but they were unable to accept it because he was not registered with them.
Camden Primary Care Trust’s Alison Kett, who is in charge of the borough’s district nurses, told the court she had investigated the incident.
She said district nurses had phoned and faxed Mr Martin’s GP to request he be referred to the unit but this was not acted on.
Dr Reid said: “The only conclusion I can reach is that Mr Martin died as a result of a recurrent accidental fall to which confusion, miscommunication, misunderstanding and loss to the anti-coagulation follow-up contributed.”
After the hearing, Mr Martin’s stepson Dave Harris said: “There were many shortcomings and a lack of communication between departments.”
He said his stepfather was mentioned in dispatches after fighting in the Battle of Monte Casino in 1944.
Mr Harris said his stepfather retired early to look after his wife, Eva, after she was diagnosed with multiple sclerosis.
A UCLH spokesman said: “Mr Martin was treated by the geriatric team at UCLH following a fall in October 2006. Requests were made by doctors at UCLH for the levels of warfarin in Mr Martin’s body to be monitored by his GP and district nurses upon his return to the community. At no point was UCLH given any indication that this request had not been acted upon.
“Mr Martin was admitted to University College Hospital in December 2006 following another fall. It then became apparent that this monitoring had not been done.” |
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