'Vibrant' Sale mum-of-two died after double-dose error, inquest hears

Alison Jayne Bailey, 40, who was also a grandmother, died at Salford Royal Hospital on August 27, 2020, from a bleed on the brain.

The court heard she had been taking 18,000 units of Deltaparin twice daily, double the recommended amount, for 14 days due to an ‘error’ in the prescription.

Alison was the mum of daughters Katie and Natasha Bailey and was devoted to her dog.

She also had two sisters Natalie Bailey and Maria Moor who gave evidence on behalf of the family at the inquest at Bolton’s Coroners Court on Monday.

The coroner Professor Dr Alan P Walsh said: “From the photos I have seen of Alison I can tell she was a vibrant individual who lived life to the full.”

The inquest heard that Alison had a complex medical history. In 2016 she had a stroke and in 2019 suffered a cardiac arrest and was given a heart valve.

That same year she suffered a bleed on the brain.

The stroke left Alison with less use of her left side making it difficult for her to walk leading to her getting a mobility scooter.

Despite this Coroner Walsh said Alison was a “strong-willed and independent person” who carried on being independent after her stroke with the support of her family.

Alison was prescribed warfarin, a blood thinner, following the stroke and cardiac arrest, to avoid clots and had regular INR (international normalised ratio) monitoring.

On August 5, Alison discovered she was pregnant following two positive pregnancy tests and told the Meadway Health Centre, which is part of the Trafford anticoagulant clinic, at a routine appointment on August 11.

Alison was told by staff at the anticoagulation clinic she would need to stop taking warfarin as it can cause abnormalities in foetuses and to instead start taking dalteparin.

Dr Rachel Brown, a consultant haematologist at the clinic, advised Raphane Kediemetse, an anticoagulant drugs specialist nurse, of the prescription change in a face-to-face meeting.

Nurse Kediemetse told the court that Dr Brown told her to write a prescription for 18,000 units of dalteparin to be taken twice daily, a normal dose of anticoagulation medicine is 9,000 units.

Dr Brown denied in court she had prescribed that dosage.

Nurse Kediemetse went to the sister in charge of the anticoagulant department Linda Coleman, with concerns over the high dosage.

Nurse Coleman reportedly told her to follow the advice of Dr Brown– a conversation Nurse Coleman told the court she does not remember.

Nurse Kediemetse wrote the prescription and then asked another consultant at the clinic, to sign it as Dr Brown was with another patient.

Dr Raj told the court he did not question the dosage as he believed the treatment plan had already been discussed with Dr Brown.

In a statement read to the court, Dr Brown said the double dosage was due to a ‘miscommunication’ between herself Dr Raj and Nurse Kediemetse.

She told the court that in hindsight she should have waited until the end of clinic to deal with the prescription and that at the time she was ‘distracted’ by blood cancer patients vulnerable to Covid-19.

Coroner Walsh said: “I find it wholly unsatisfactory people in charge of an anticoagulation clinic have a different or no recollection of something that led to the death of a patient.

“At present there is no clear evidence of how this happened. I am obviously disturbed I can’t get to the truth and extremely concerned by the conflict in the evidence given by witnesses.”

On August 12, Alison went to the Early Pregnancy Assessment Unit at Wythenshawe Hospital with fears she was miscarrying.

It is still unknown whether Alison was suffering a miscarriage at the time.

She attended the Early Pregnancy Assessment Unit again on August 19 and was given enoxaparin at the correct dose but was then discharged with a letter saying she should continue to take 18,000 units of dalteparin twice daily.

Four days later on August 23, she went to A&E with a severe headache with her daughter Katie who told the court that her mum was so sensitive to light at the time she was wearing sunglasses inside. She also said her mum was vomiting.

Alison was discharged with a migraine diagnosis.

Her headache continued and on August 26, she attended A&E at Salford Royal Hospital and a CT scan showed she had an extensive haemorrhage.

She deteriorated quickly and sadly passed away at 6.30am on August 27.

Consultant neuropathologist Dr Daniel Plessis said the cause of death was a spontaneous intracerebral haemorrhage and that Alison’s previous stroke and new stroke combined with an excessive blood-thinning treatment played a part in the development of the bleed on the brain.

Alison’s endocarditis, which necessitated a heart valve treatment, was a contributary factor but not the primary cause of death.

Dr Daniel Plessis said it was likely the bleed on the brain started when she initially complained of a headache.

The Manchester University NHS Foundation Trust, which was responsible for Alison’s care, accepted there was a prescription error and that this error should have been identified.

Had it been, Alison would most likely have survived. The Trust has expressed its condolences to Alison’s family.

Coroner Walsh said: “I have never had an admission like this one in 25 years."

He did not, however, issue a prevention of future deaths report saying that action was and is being taken to address the “number of concerns” he had in relation to the trust.

Coroner Walsh did express his disbelief that the incorrect prescription, which should have been a ‘shining beacon’, ‘passed through so many hands’ and that multiple opportunities to rectify the dose were missed.

Alison’s sister Maria said: “Nothing is going to bring Alison back. We have found the cause of death and moving forward things have to change.”

Dr Simon Watt, the lead consultant at Wythenshawe Hospital, led a full review into the treatment and care Alison received at the trust.

Within the trust nurses no longer write prescriptions and now have one hour a day scheduled to discuss patients with doctors with all conversations documented.

All conversations between staff regarding patients are now documented.

Price Slater Gawne solicitor Sophie Fox, who is assisting the family with the inquest and subsequent legal investigation, said: “Alison was a much loved and irreplaceable member of her family.

“This is a tragic case where the death of a young woman should have been avoided.

"We are pleased that the trust has admitted responsibility and hope the inquest provides the family with the answers they seek.

"It is important the trust takes appropriate action to ensure that this mistake never happens again.”

The coroner recorded a narrative conclusion to the inquest.