Deaths from cardiovascular disease involving anticoagulants: a systematic synthesis of coroners’ case reports

Abstract

BackgroundThe global burden of cardiovascular disease (CVD) is forecast to increase, and anticoagulants will remain important medicines for its management. Coroners’ Prevention of Future Death reports (PFDs) provide valuable insights that may enable safer and more effective use of these agents.ObjectiveTo identify CVD-related PFD reports highlighting the use or lack of anticoagulants as having caused or contributed to deaths.MethodsWe conducted a retrospective observational study of coronial case reports in England and Wales between 2013 and 2019. We screened 3037 PFDs for inclusion and used content analysis to assess concerns raised by coroners and who responded to them.ResultsWe identified 113 CVD-related PFDs (113 deaths) involving anticoagulants. Warfarin (36%), enoxaparin (11%), and rivaroxaban (11%) were the most common anticoagulants reported. In 14 cases, the coroner mentioned that the administration of an anticoagulant may have prevented the death. Concerns most frequently raised by coroners included poor systems (31%), poor communication (25%), and failures to keep accurate medical records (25%). These concerns were most often directed to NHS trusts (29%), hospitals (10%), and general practices (8%), but had national importance. Nearly two-thirds (60%) of PFDs had not received responses from such organisations, which are mandatory under regulation 28 of the Coroners’ (Investigations) Regulations 2013.ConclusionsWe created a tool (https://preventabledeathstracker.net/) that bring together coroner reports to identify important lessons related to preventable deaths. Here we examined instances of premature deaths from CVD involving anticoagulants. National organisations, healthcare professionals, and prescribers should take actions to address these concerns, to improve the use of anticoagulants in patients with CVD.Key questionsWhat is already known?A previous assessment of 500 PFDs identified anticoagulants as the class of drugs most often involved in fatal medication errors.What does this study add?We used innovative methods to automatically collect all available PFDs, in order to identify deaths from cardiovascular disease when the use of or lack of anticoagulants caused or contributed to the death. We found that communication, following protocols, education and training, access to resources, and safety issues were raised as concerns by coroners. Despite having national relevance, most CVD-anticoagulant PFDs were sent locally to NHS Trusts, hospitals, and general practices.How might this impact on clinical practice?Local dissemination and poor responses to PFDs limits the ability of lessons to be learnt and actions to be implemented to reduce harms and prevent premature deaths from cardiovascular disease involving anticoagulants. The concerns highlighted by coroners should be addressed by national organisations to improve safety and management of patients with cardiovascular disease.