AN ELDERLY Cirencester woman's death after she was prescribed too much of the blood-thinning drug Warfarin has prompted a coroner to call for a blood-test-at-home service to be re-instated.

In the wake of Janet Baxter-Mead's death, county coroner Alan Crickmore is to write to the Gloucestershire Primary Care Trust and to her GP practice in a bid to prevent a similar tragedy.

An inquest in Gloucester heard that mum of six Mrs Baxter-Mead, 84, of Rodmarton Manor, nr Cirencester, was reliant on her elderly husband for transport to hospital for regular blood tests.

She could not have tests at home because district nurses would not attend people who were not considered to be housebound.

But after a period when her husband was in hospital and she was cared for in a respite home, she was over-prescribed Warfarin, the inquest heard.

Her GP Dr Ian Simpson said a blood-test-at-home service had once operated successfully in the Gloucester area but been discontinued.

Mrs Baxter-Mead, of Rodmarton Manor, near Cirencester, died in Cheltenham General Hospital on August 18, 2008.

Consultant pathologist Dr Keith McCarthy said she died of heart failure following severe gastrointestinal bleeding caused by increased levels of Warfarin.

Her husband Dennis Mead said they had been married for 65 years and had six children.

His wife had started on Warfarin six to eight years ago after suffering an irregular heart beat, he said. She had a blood test every six weeks at Cirencester hospital. She was notified of any changes in her dosage by telephone, although it usually stayed the same.

On June 29, 2008, said Mr Mead, he was admitted to hospital and his wife then had a fall at home and was taken into respite care at Paternoster House in Cirencester.

When they were both back home in late July they had a call from the out-of-hours service advising his wife to increase her dosage of warfarin to 11mgs over three days. Her previous, normal dose was just 4mgs in that period.

"I thought that level was enormous and spoke to the doctor on the phone to confirm the levels," said Mr Mead.

A doctor from Phoenix practice in Cirencester visited his wife on August 5, examined her, took a blood sample and advised her to stop taking warfarin, he said.

Two days later, they were sitting on the settee when his wife began to vomit dark-coloured blood.

"It was just like and explosion. I had never seen anything like it before," Mr Mead said.

Mrs Baxter-Mead was admitted to Cheltenham General Hospital but her condition deteriorated and she died on August 18.

Stephen Bates, the pathology laboratory manager for Gloucestershire NHS Trust, said a blood sample taken from Mrs Baxter-Mead by district nurses at Paternoster House on July 25 showed her warfarin level was well below the therapeutic range.

This information was passed to the out-of-hours duty staff. Mr Bates said this information was also transmitted to the patient's GP surgery.

Dr Rosemary Ginns was on duty as the out-of-hours GP when she received information about Mrs Baxter-Mead's blood test on July 26. Dr Ginns said she telephoned the patient, explained her very low INR blood test result and advised her to increase her warfarin dose to 5mg that day and 3mg the following day.

The information was also transmitted by fax to the surgery with a follow-up instruction for the surgery to contact the patient, she said.

Dr Simpson told the inquest he was on holiday at the time of Mrs Baxter-Mead?s blood test.

At that time, the practice secretary would put the fax into his in-tray and, in his absence, it would have been passed to his colleague, Dr Chris Goldie.

Now all documents are scanned into the computer system, it would still be placed on a doctor’s ‘hook’, but any need for follow up action would be highlighted. After his return from holiday, Dr Simpson said he was informed of the result of a blood test carried out by Dr Goldie that indicated very high levels of warfarin. Throughout the day on August 6, he had attempted to contact Mrs Baxter-Mead several times by telephone, but had been unable to do so.

Dr Simpson said although in Cirencester there was a simple system whereby blood tests are carried out, without an appointment, at the hospital there was a problem county-wide for those who were not deemed to be housebound, but who had difficulties in travelling to hospital or a surgery.

He spoke to Mr Baxter-Mead on August 7 who told him his wife had coughed up a small amount of blood. Dr Simpson told him there was an 'urgent need' for another blood test and he agreed to take her to hospital.

Later that day, Mr Baxter-Mead called again to report his wife had vomited blood. Dr Simpson attended at their home, administered a vitamin K injection to counteract the effects of warfarin and she was taken by ambulance to hospital.

Dr Goldie said his first contact with the patient had been on July 31 when he spoke to Mr Baxter-Mead who told him he felt the warfarin dose prescribed by the out-of-hours service was too high - and that he had restricted it to 3mg each day.

He was later asked to make a home visit where he took a blood sample and told the patient to stop taking warfarin, he said.

Consultant haematologist Dr David Perry of Addenbrooke's Hospital, Cambridge, an independent expert, said if Mrs Baxter-Mead had received a vitamin K injection and different treatment when she arrived at hospital, the outcome might have been different.

The coroner said he was convinced that had Dr Goldie seen the out-of-hours report he would have acted upon it. The system had now changed and the need fo follow-ups are highlighted.

Mr Crickmore said the opportunity to administer an earlier vitamin K injection was lost but it was not clear that it would have been enough to change the final outcome.

The coroner said he was satisfied there were no gross failures or any neglect by anybody involved in the care of Mrs Baxter-Mead.

In his narrative verdict, he said Mrs Baxter-Mead died from the effects of an elevated warfarin level that occurred because she had taken an excessive dose between July 26 and August 5, 2008. She had failed to follow the advice of two doctors and she did not attend for regular blood tests.

Mr Crickmore said the situation was exacerbated by the lack of an adequate system to ensure advice was followed up.

The coroner said he would be writing to the Gloucestershire Primary Care Trust inviting them to consider introducing a county-wide blood-test-at-home service for those vulnerable patients like Mrs Baxter-Mead who were clearly disadvantaged but not deemed to be housebound.

He would also be writing to the Phoenix GP practice encouraging them to improve patients’ understanding by introducing a system where a note would be sent to inform them of any changes in medication or dosage, he said.