Mary Bloom
30 Oct 2015 · Coroner Nadia Persaud · East London
The coroner's concerns
1. failure to weigh patient before heparin administration
“There was a failure to comply with the Trust's policy relating to the administration of heparin, by failing to weigh Mrs [name redacted] prior to commencing the infusion of heparin”
2. failure to consult haematologist for low weight patient
“There was a failure to consult a haematologist before the infusion of heparin in view of Mrs [name redacted]' very low weight of 30 kilograms”
3. failure to obtain post-hydration blood tests
“It was not possible to take baseline bloods before the commencement of heparin, however, attempts should have been made to retake bloods after hydration had commenced”
Responses
2015-0417-Response.pdf ↗· Barking
Stated action
“The Trust's new policy is for a weight based bolus and then a weight based infusion the latter within weight ranges. Even with a patient of 25kg the infusion would be at 20iu/kg/hr which is a very reasonable infusion rate and in line with recognised dosage rates even at this weight. The APPTR must be checked at 6hours and this allows the dose to be adjusted within recognised time intervals. We therefore feel that the safeguards are,in place as we have moved to an entirely weight based formulati”