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Alleged anticoagulation failure

Ms S was a 51-year-old teacher. At the start of term, Ms S developed a troublesome cough and went to see her GP, Dr B, about it. Dr B diagnosed a chest infection and prescribed antibiotics but also noted that she had an irregular pulse. An ECG was performed at the surgery the same day, which showed that Mr S was in atrial fibrillation. Dr B sent Ms S to the medical assessment unit for urgent review.

The hospital doctors confirmed the diagnosis of atrial fibrillation and prescribed warfarin
to reduce her risk of thromboembolic stroke and bisoprolol to slow her heart rate. They put Ms S on the waiting list for a cardioversion procedure and discharged her home.

Ms S attended for her cardioversion procedure but was found to be in sinus rhythm. The cardiologist (Dr T) advised Ms S to stop taking her warfarin and to reduce her bisoprolol. Dr T gave Ms S a medication slip to take to her GP, which detailed his advice, and told her that she would be called back to clinic for follow-up.

Dr B saw Ms S again with the cardiologist’s advice slip.

Dr B documented that her pulse was regular now (although she was slightly bradycardic).

Dr B arranged a further ECG
for the following week and reduced her bisoprolol dose further. Dr B documented that Ms S was “awaiting cardiology follow-up” and that she had had a chest infection when the atrial fibrillation was initially diagnosed.

The ECG the following week showed sinus rhythm with a rate of 60bpm. Dr B saw Ms S again to inform her that her ECG was normal. Dr B noted her pulse on that day was regular and that she was waiting for cardiology review.

Soon after, Ms S received a letter asking her to return for another cardioversion procedure. Ms S rang the cardiologist’s secretary to explain that she had been advised that this was not necessary but that she was waiting for an outpatient appointment.

Dr B received a letter from the warfarin clinic stating that she had not attended for INR testing for at least four weeks.

Dr B circled the response “no longer requires anticoagulation”.

A month later, Ms S suffered a stroke. There were no other risk factors for stroke identified other than atrial fibrillation, thus the likely cause of Ms S’s stroke was an embolic event arising as a consequence of thrombus formation within the atrium.

As a result of the stroke, Ms S felt unsteady and hesitant every time she walked. Despite rehabilitation, her writing was slow and clumsy and she slurred her words. Sadly, teaching was no longer possible and Ms S had to retire early on grounds of ill health.

Ms S was devastated. She felt that her stroke could have been prevented if she had been anticoagulated. Ms S made a claim in negligence against Dr B.

It was alleged that Dr B should have prescribed some form of anticoagulation and that
he should have contacted the hospital to query the medication position, especially in light of the non-attendance letter from the anticoagulation clinic.

Expert opinion

Medical Protection sought the advice of an expert GP, Dr H. Dr H felt that the care given by Dr B was of a reasonable standard. Dr H did not consider that Dr B had a mandatory duty to prescribe anticoagulation or that he should have contacted the hospital to query the medication position. Dr H noted that the decision to stop anticoagulation had been clearly relayed on an advice slip from a cardiologist. Ms S had also told Dr B that she was waiting for cardiology review and her subsequent ECG had shown sinus rhythm.

The opinion of a professor in stroke medicine (Prof G) was also obtained by Medical Protection. Prof G confirmed that the likely cause of Ms S’s stroke was thromboembolic. Prof G pointed out that some patients develop atrial fibrillation secondary to other illness such as chest disease.

In such a setting, if the atrial fibrillation resolves when the underlying cause has been treated, and the clinician feels that there is a low risk of it recurring, then it is reasonable not to anticoagulate.

Ms S would have had a CHA2DS2-VASc score of 1 because of her sex but an absence of congestive heart failure, hypertension, diabetes, stroke or vascular disease and
age below 75 years. Prof G felt that it would have been quite reasonable not to anticoagulate in this context.

Medical Protection served a letter of response denying liability and Ms S did not pursue the claim any further.

Learning points

The UK’s National Institute for Health and Care Excellence (NICE) guidelines, Atrial fibrillation: the management of atrial fibrillation (June 2014) states that doctors should consider anticoagulation for men with a CHA2DS2-VASc score of 1 and to offer anticoagulation to people with a CHA2DS2-VASc score of 2 or above, taking bleeding risk into account.

Documentation of the reasons behind the decision-making was invaluable in defending this case.

This case report article was reproduced with the permission of Medical Protection.

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