Warfarin drug dispension rules tightened following Tooting woman's death (From This Is Local London)
Warfarin drug dispension rules tightened following Tooting woman's death
6:30am Tuesday 3rd November 2009 in
Rules on how blood thinning drugs are dispensed to patients have been tightened following the death of a woman who received repeat prescriptions without pharmacists checking she was taking the correct dosage.
On Friday, Westminster Coroner’s Court ruled Ann Wildish died from natural causes, brought on by heart failure.
But, the coroner Dr Shirley Radcliffe said, her case had highlighted flaws in the way potentially lethal drugs were dispensed.
Mrs Wildish, 54, collapsed at her Cowick Road home in Tooting about 5.30pm on June 25.
She was taken to St George’s Hospital, where blood started pouring from her nose and mouth, and died just after 10pm that evening.
The court heard Mrs Wildish was on a course of Warfarin for deep vein thrombosis, and was also suffering heart failure and respiratory problems.
However, it emerged Mrs Wildish, who missed blood tests, was given repeat prescriptions of Warfarin - which can be lethal if the level in the blood gets too high - without seeing her GP.
Pharmacists also failed to check whether she had been for a blood test, to determine Warfarin dosage, before dispensing her the drugs, the court heard.
While this did not contribute to her death, and there was no suggestion the GP did anything wrong, the current system could lead to other patients taking potentially fatal doses, the coroner said.
Mrs Wildish’s GP, Dr Michael Lane at the Dr Freeman and Partners Surgery in Upper Tooting Road, said the surgery had since taken steps to improve the checking system.
A warning note would be raised on the surgery’s computer system to ensure Warfarin patients had completed a blood test recently, he said.
And pharmacists would now have to check patients had received a recent blood test before dispensing the drug.
The new guidance was being sent to other surgeries.
Dr Radcliffe said the inquest had been “useful” in understanding the dispensing process.
She said: “In this case it didn’t play any part, but it has highlighted something that, perhaps, needs to be reviewed - [that] pharmacists are now checking repeat prescriptions of Warfarin.”
The coroner previously adjourned the inquest after evidence pointed to the amount of Warfarin in her blood being too high.
But after hearing further evidence, the coroner ruled the bleeding and heart failure most probably caused the high reading.
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