IS sending a time-sensitive letter about a patient by ordinary post an archaic means of transmission in 2015?
The recent findings of an inquest by the South Australian Deputy State Coroner Anthony Schapel into the death of Marjorie Irene Aston
suggest that the answer is “yes”.
Mrs Aston, aged 86 years, had consulted a cardiologist just before Christmas, a month before she died. He recommended she begin warfarin therapy of 5 mg once daily for her atrial fibrillation, replacing the aspirin she had been taking for the condition.
The cardiologist (in the patient’s presence) dictated a letter to her GP about her starting warfarin therapy and advised of the need to test and adjust the dose in the usual way.
The letter needed to be typed and posted through a hospital mail system. The delivery process was known by the cardiologist to take some time, up to 10–14 days.
The coroner noted: “The letter would neither be faxed nor emailed to its intended recipient; such modern means of transmission not being routine in his practice.”
Because of the intervening Christmas period, the letter did not reach the GP until some 3 weeks later — 4 days after the patient had died of a right subdural haematoma, contributed to by excessive warfarin anticoagulation.
The GP had visited Mrs Aston at her home before her death when he discovered she was taking warfarin. He advised her to stop taking the drug on that visit.
The coroner outlined a series of factors that contributed to her death including failure of the patient to follow the specialist’s instructions to contact her GP and failure to have the GP copied to receive pathology test results that the specialist had ordered.
It was noted that the specialist had repeatedly insisted that it was common practice for a specialist to communicate with a GP as he had in Mrs Aston’s case — by sending a letter by ordinary post and providing oral advice to the patient.
However, the coroner made it clear he was unhappy with the cardiologist’s administrative practice, describing it as an archaic means of transmission, fraught with imprecision and bound to fail in due course. He went so far as to say: “I would have grave difficulty in describing it as a professional clinical practice”.
The coroner also noted that the GP’s practice and the hospital where the specialist was based were separated only by a car park.
Mr Schapel recommended that in circumstances where a specialist initiates warfarin therapy but does not intend to manage that therapy, the specialist should immediately advise the patient’s GP by the most efficient method of communication available.
It was also recommended that the practice of specialists prescribing warfarin in the first instance in the expectation that a GP would then manage the therapy be revised, saying consideration should be given to whether the GP, on the advice of the specialist, should both initiate and manage the patient’s warfarin therapy.
He also advised that specialists should not place undue reliance on the patient advising the GP that warfarin therapy had been initiated by the specialist.
Mr Schapel said that “the practice of communicating with general practitioners by way of ordinary post should be curtailed and be replaced by a means of communication that would include email and/or facsimile transmission … it may be necessary in some cases for the specialist to communicate with the general practitioner by phone …”.
Perhaps specialists should follow the same advice on standards and ensure they have the quickest and most efficient means to communicate with GPs.
Mr Bill Madden is the National Practice Group Leader, Medical Law, with Slater and Gordon.