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Failings identified in drugs regime of patient who died following heart surgery

By Cate McCurry

Published 15/11/2016

Bernadette Hannaway and other family members with a photo of her late husband, Alfie
Bernadette Hannaway and other family members with a photo of her late husband, Alfie
Alfred Hannaway

the widow of a man who died following a series of failings in his medication plan has told a court that he was a gentleman who was the "centre of their family".

Alfred Hannaway (61) - known as Alfie to friends and family - died after undergoing major heart surgery.

The father-of-eight from west Belfast had been taking the blood-thinning drug Warfarin following his surgery at the Royal Victoria Hospital in August 2013.

He died of a haemorrhage weeks later.

During a two-day inquest into his death, Belfast Coroner's Court heard how there were a number of mistakes in communications between the cardiac team, the Warfarin Clinic at Belfast City Hospital, and the family's GP surgery.

Alfie's wife Bernadette said he was badly missed by his family.

"He was the centre of our house. He was always there for anyone," she explained.

"If anyone had any troubles they would go to Alfie. He would take their hands and hold them to his chest. They would look into his eyes and he would say, 'Everything will be all right'."

His children, who were also in court, wiped away tears as their mother recalled happier times at the family home.

"He loved to tell stories," she added. "He had a great faith and wrote a couple of hymns, one of which was played at his funeral. He was always willing to help.

"He was always positive that he would get better and put his full trust in the health service. He had great admiration for them. He took great care of his tablets, too."

She also described the moment she woke up in the early hours of September 21 after hearing gurgling noises. "I got out of the bed and went over to him. His tongue was hanging out of his mouth and it was pure black."

The taxi driver's death was the subject of a Serious Adverse Incident (SAI) investigation which raised a number of concerns into the management of his medication. The health trust apologised following the series of failings identified in his care.

The court heard how his Warfarin dosage was written down in what is known as a 'yellow book', which records the monitoring of the medication.

Following his discharge from hospital, Mr Hannaway was given a new yellow book with a lower dosage of Warfarin. However, his old book - which contained his high dosage level prior to his surgery - remained in his possession.

Staff nurse Josephine McDonald, who visited Mr Hannaway days after he was discharged, took a blood sample and sent it to the Royal Victoria Hospital with a copy of his outdated yellow booklet.

The blood sample and old book were used to calculate his new Warfarin dosage.

Staff nurse Pauline Hanna, who works at the Warfarin Clinic, told the court she was not aware he had major surgery when she prescribed the higher dosage. She said that the pair shared a close relationship and that she would have expected Mr Hannaway to contact her if he had undergone surgery.

The court also heard that the Warfarin Clinic, located at Belfast City Hospital, was never made aware of his operation.

There was also confusion over the discharge letter which stated that his Warfarin monitoring was in the care of his GP. However, that information was wrong.

The family's GP, Dr JP Connolly, admitted the surgery "could have done more" to communicate with the clinic after receiving the discharge letter.

Dr Gary Benson, a consultant haematologist with the Belfast Trust, told the coroner's court in his evidence that Warfarin was one of the most dangerous drugs provided by the trust and its use required close monitoring.

The inquest continues.

Belfast Telegraph

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