A Hay-on-Wye woman died of natural causes despite a lack of clarity about medication when she was discharged from hospital

Mary Maureen Powell passed away at Bronllys Hospital on April 11 2024 after suffering a stroke on April 8 2024.

The 91 year-old retired care assistant who lived at Gypsy Castle in Hay-on-Wye had a number of health conditions and had taken aspirin since 2014 for a heart condition and risk of a stroke.

An inquest at Waterton Technology Centre in Bridgend on Tuesday heard that Mrs Powell was admitted to Hereford County Hospital on February 17 2024 and suffering with pneumonia and atrial fibrillation.

Her aspirin medication was stopped and instead she was given edoxaban, an anticoagulant.

She was moved to Ross-on-Wye Community Hospital on February 29, but her family were unhappy with conditions and self-discharged her on March 2.

South Wales Central Coroner Kerrie Burge heard from consultant geriatrician Dr Emma Wales that there are reduced staff in Ross Hospital on the weekends and with an unplanned discharge it led to delays in the electronic discharge summary being sent on to Mrs Powell’s GP surgery. They only received it on March 22.

Dr Wales said changes have now been made to ensure doctors on the next working day are told of any unplanned or weekend discharges so they can complete the electronic discharge summary sent to GP’s

Staff at Ross Hospital had given Mrs Powell’s family a medication list but they did not give them any medication supplies.

Ms Burge said a number of assumptions were made during the discharge – Mrs Powell’s family believed they had the medication for her at home- they did not realise she had been started on edoxaban. As a result she was given aspirin.

The Haygarth Medical Centre believed seven to 14 days of medication would have been given to Mrs Powell, they did not check and the pharmacy and GP team did not have the discharge summary to prompt them.

On March 20 Mrs Powell was re-admitted to hospital and both aspirin and edoxaban was administered.

Mrs Powell suffered a bleed on March 25 and the edoxaban was stopped.

Ms Burge said a lack of clarity on discharge medication resulted in Mrs Powell not being given her new medication from March 3 until 19 and she was given aspirin, and from March 20 to 22 she had received aspirin and edoxaban increasing her risk of a bleed and then the anticoagulant edoxaban was stopped.

But she said it was not clear if this had contributed to Mrs Powell’s death and she may have developed a stroke in any event because of her age and frailty and her pre-existing health conditions.

She concluded Mrs Powell died of natural causes as a result of pneumonia, atrial fibrillation, carotid artery and a cerebral vascular event.

Ms Burge told the family she was happy that changes made by Herefordshire and Worcestershire Healthcare NHS Trust to improve practices around unplanned and weekend discharges will help to prevent a similar situation happening again.

She said she also believed the GP surgery will reflect on whether they should ask patients and families about medication supplies after a hospital discharge. She said she did not need to take any further action.

Ms Burge extended her condolences to Mrs Powell’s family.