Background

A 42-year-old patient moved to a new state and established care with a new Primary Care Provider (PCP). The patient provided the PCP with a list of medications he’d been taking for years, one of which was Coumadin, a blood thinner.

To screen for colon cancer, the PCP advised the patient to undergo a colonoscopy and ordered him to stop taking Coumadin five days prior to the procedure. The patient followed instructions and returned to the PCP to find out his colonoscopy was clear. During the appointment, he told his provider he was unaware of why he was taking Coumadin for so long, and the PCP did not reorder it after the colonoscopy.

After two weeks, the patient died suddenly from multiple blood clots to his lung, heart, and brain. It was subsequently alleged that the PCP should not have discontinued the Coumadin.

Services Provided

Our Legal Nurse Consultant (LNC) reviewed the medical records late in the litigation process, three weeks prior to trial, at the request of the defense client. Already retained were two testifying experts, who supported the care given by the PCP. Their deposition testimonies stated there were no indications in the medical records that the patient needed to take Coumadin.

When reviewing the medical records, Rimkus’ LNC found a hematologist’s barely legible handwritten note from years prior that stated the patient had antiphospholipid syndrome (APS) and would require lifelong anticoagulation via Coumadin.