A WREXHAM pensioner died after suffering a stroke likely to have been caused by the failure to end her prescription for an anti-coagulant drug, an inquest heard.

Freda Duckers died, aged 79, in Emral House Nursing Home on October 9 last year, four months after a 14-week stay at Wrexham Maelor Hospital.

She underwent bowel cancer surgery in November 2016 after developing clots on her lungs and was prescribed the blood thinning drug Apixaban.

But the Ruthin hearing was told the drug should have been discontinued after six months, yet her prescriptions carried on from the Plas Y Bryn GP surgery in Wrexham for over a year.

An investigation identified that a discharge check list was not completed when the pensioner left hospital.

A follow-up appointment to review Mrs Duckers’ medication never took place and these failures of communication ultimately led to her death.

Coroner North Wales and Central Elizabeth Dudley-Jones said: “It is clear that without these unfortunate events she would not have died.”

When medics suspected drugs prescribed at the hospital may have caused her stroke a serious incident review was launched.

Dr Mark Steel, a respiratory consultant, said that Mrs Duckers had been initially treated with Warfarin after her admission in 2016 when she suffered a pulmonary embolism.

But her medication was switched to Apixaban, which the medic said was more commonly used to treat and prevent blood clots.

He said the intention was to review Mrs Duckers’ treatment after three months using an echocardiogram to check there had been no complications with the embolism and that after six months the anti-coagulant would have been stopped.

But the next time he saw the pensioner was when she was admitted following her stroke.

“It was evident there clearly had been a failure following up the medication,” said the medic, who said he went to see the pensioner on the ward, but “she was not in a fit state to have a conversation”.

Dr Steel admitted: “It was more likely the Apixaban caused her stroke or increased the severity of it.”

A post-mortem found that the cause of death was bronchial pneumonia and a cerebral haemorrhage.

Dr Steel said that a junior doctor would have been tasked with writing the patient's discharge letter, but it did not include details of a follow-up appointment.

But the medic said that an audit process was now in place to track discharges and that doctors now stated clearly how long anti-coagulants were meant to be prescribed for because of the bleeding risks.

He said he was saddened that Mrs Duckers had suffered a “potentially avoidable stroke”, but added: “There is a lot of pressure to get people out of hospitals and nursing staffs are lower and these are all factors that add to the risks.”

Dr Minnal Nadaph, a GP at Plas Y Bryn, said the pensioner attended the surgery in May and June 2017 complaining of pain in her legs and tiredness, but she continued to receive Apixaban.

The doctor said it had not been made clear that the drug was not a “life-long” drug, but since Mrs Duckers’ death such medications were now being monitored in the surgery’s IT system where they were clearly marked with stop dates.

The coroner issued a narrative conclusion and said there had been a failure to follow up the pensioner’s treatment and discontinue anti-coagulant therapy.

She said that she was satisfied the surgery was reminding patients to attend medication reviews, although she noted that in 80 to 90 per cent of cases medication forms were not reaching GP surgeries from hospitals.

Mrs Duckers’ daughter, Ruth McKay, said her mother who had worked as a shop volunteer for Hope House, had lived in a warden-controlled flat.

But after leaving hospital she “went downhill” in nursing home.

“This was an extremely unfortunate and sad set of circumstances," added the coroner.