Mrs A was transferred home, and she died a short time later. On Day 9, Dr C disclosed to Mrs A’s family that a potential medication error may have contributed to Mrs A’s deterioration.Anticoagulation with dabigatran and Clexane was stopped, and Mrs A was transferred to the intensive care unit, where her condition deteriorated. Dr C consulted with the on-call haematologist at another district health board (DHB2), and learned that co-administration of dabigatran and Clexane is not recommended. Dr C planned to reverse the dabigatran with Praxbind. On Day 8, Dr C ordered a CT scan of the head, which showed a new subdural haemorrhage in the posterior fossa. Initially, Mrs A appeared to be recovering, but on Day 7, she had a severe headache and elevated blood pressure.Either medicine can be used to treat PE, but they should not be administered together. Dr C then started Mrs A on a further blood-thinning medication, dabigatran, in addition to enoxaparin. On Day 4, following a delay owing to equipment failure, Mrs A had a CT scan of her chest, which confirmed bilateral PE.Later that day, Mrs A was started on enoxaparin (Clexane) in case she had a PE, and her clopidogrel treatment was stopped. The SOB was thought to be secondary to a pulmonary embolism (PE), or an exacerbation of her chronic obstructive pulmonary disease (COPD). On the morning of Day 2, Dr C started Mrs A on antibiotics for a urinary tract infection, and clopidogrel and aspirin for a transient ischaemic attack (TIA). Mrs A was under the care of a senior medical officer, Dr C.Mrs A (aged 75 years) presented to the Emergency Department of a public hospital in 2016 feeling generally unwell with a headache, shortness of breath (SOB), a tight chest, nausea, and lethargy, and was admitted to the Medical Assessment & Planning Unit.Other comment - delay in prescribing PraxbindĪppendix A: Independent advice to the Commissioner Information gathered during investigation Senior Medical Officer, Dr C Lakes District Health BoardĪ Report by the Health and Disability Commissioner Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name. Names have been removed (except Lakes DHB and the expert who advised on this case) to protect privacy.
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