A Pacific health provider has made changes to the way it monitors some of its patients after a woman died of a brain bleed - after not receiving a test that would have shown a risk of a blood clot, for more than a year, a Coroner has found.

Neomai Moa Akauola died in September last year days after hospital scans found the presence of haemorrhagic legions - bleeding in the brain - which could not be operated on.

The 83-year-old’s family was told her prognosis was poor and palliative care was provided as a result. She died a few days after being admitted to Auckland City Hospital.

A Coroner’s finding shows the pensioner had been on warfarin medication - a blood thinner - which was prescribed in 2016 for stroke prevention.

Anyone on warfarin is required to undergo an INR (international normalised ratio) test regularly - a test that measures the time it takes for a clot to form in a blood sample and therefore show any risk of a blood clot or bleeding.

Documents show Akauola had not had an INR test since April, 2020.

Her recommended range was said to be between 2.0 to 3.0. When she was taken to Auckland City Hospital, blood tests showed her INR was above 10.

The Coroner called on a medical advisor for expert advice regarding the case.

The medical advisor, named in documents as Dr Murdoch, reviewed Akauola’s medical records; which showed three health professionals at her GP clinic - Langimalie Clinic - continued to prescribe warfarin for her despite no further INR testing.

On four occasions, the health professionals at the clinic ordered blood test for the pensioner - but none of them requested an INR test be carried out.

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“Dr Murdoch advised that it is very important for patients taking warfarin to have this monitored by regular INR blood tests, and to have the dose of warfarin adjusted according to the results, with the aim of keeping the INR result within a specified range.

“[She] noted that if the INR values are greater than 3.0, the risk of bleeding is increased,” the Coroner’s finding says.

“Dr Murdoch expressed concern about the safety of other patients on warfarin at Langimalie Clinic and believed that an urgent audit of all the patients on warfarin was necessary to check they were receiving appropriate monitoring.”

Changes made after death

The Langimalie Clinic - under the Tongan Health Society - is a well-known branch of clinics in the Auckland region for Pacific families and particularly those in the Tongan community.

After Akauola’s death, Langimalie advised that as a result of the failure to monitor INR levels, clinical staff - including doctors and nurses alike - met to talk about procedure changes, the Coroner said.

The clinic implemented immediate changes involving their computerised systems; creating an INR patient register that shows a particular patient’s medication dosage, date of INR results and the doctor’s decision for the next INR testing event.

The changes will also see the register being updated each time a doctor receives a new INR test result from a registered nurse.

An “INR Champion” has also been appointed at the clinic and whose responsibility it is to include weekly maintenance checks of the register and actively recalling and tracking patients that remain overdue for their next INR test.

The Coroner said the failure by successive doctors at Langimalie to monitor Akauola’s INR while continuing to prescribe her warfarin medication was “very concerning.”

“This continued over an 18-month period, so was not an isolate event. No real explanation for this failure was provided other than a breakdown in communication’.”

Coroner urges all GPs to review monitoring systems

The Coroner said they would not be making any direct recommendations to Langimalie.

However, the incident had led to the Coroner wanting to draw the importance of INR monitoring when prescribing warfarin to the attention of all general practitioners.

“While this may be basic prescribing practice, in busy practices it is understandable that, without adequate processes and procedures, it could be missed.

“Given the very serious consequences of failing to monitor INR for patients on warfarin, I encourage all general practitioners to review their management protocols for patients prescribed warfarin or other anti-coagulants in order to optimise patient outcomes and minimise risks.”