Inquest: Closer eye needed on “life-saving” drug’s long-term effects

Thursday 07 October 2021

Health professionals should keep a closer eye on patients taking a drug to treat irregular heart rhythms and other conditions for an extended time, an inquest into a pensioner’s death has concluded.

While digoxin was referred to as “life-saving” during yesterday’s hearing, Coroner Mark Harris was told that more needs to be done to monitor its effects on long-term users.

After concluding that a 94-year-old woman had died from heart failure resulting from having too high a level of the drug she had taken for 20 years in her body, the Coroner said he would write to the hospital to share the recommendation.

The elderly woman passed away in January 2020, having been admitted to A&E on New Year’s Eve after suffering an erratic heartbeat and confusion.

Earlier in December, she had been to see her GP on a separate matter, but was referred to the hospital for a blood test to check the levels of digoxin in her blood.

But the GP was unable to interpret the results when they were received, as the time that the woman had taken the drug before being tested was not clear.

Pictured: Morier House, where the inquest was heard by Deputy Viscount Mark Harris, sitting as Coroner.

It was explained during the inquest that the hospital's process required six hours to have passed between taking the drug and the hospital taking the test, as levels would read as higher after initially taking it.

Police Coroner's Officer Tony Forder noted that he found no record the hospital had booked a follow-up appointment to do the test again, though protocol is for another appointment to be created.

The Deputy Viscount noted that "events overtook the process" following this, and the woman also developed a chest infection.

Though her GP said the infection appeared to be clearing by 27 December, by 29 December he found it had worsened again, and on 31 December he had her admitted to the Emergency Department.

On admission, her digoxin levels were taken by medics and it was found she had more than three times the normal digoxin amount in her blood.

It was noted by Professor William Roche - who wrote the post-mortem report - that the woman was on a high prescription for her age, taking 375 micrograms daily, whereas the usual dose would be 125 micrograms.

Her GP said he had seen no reason to change the dose she was on when she came into his care, as she had been on it for over 20 years, and he had found her to be "quite well" prior to the December this had taken place, performing regular checks on her chronic renal condition.

Her digoxin levels taken in 2017 were also in the normal range.

The GP also pointed to NICE guidelines advising that “there is no evidence from randomised controlled trials to indicate that regular monitoring [of digoxin levels] confers better outcomes”.

Summing up his findings, Professor Roche said that he felt for someone of the woman's age and with other medical issues such as her chronic renal disease, it was an "unusually high dose" and he would expect a mix of routine checks and occasional blood tests with it.

He concluded that that her death was due to heart failure as a result of having toxic levels of digoxin in her body, combined with the other conditions she had.

He said that having a good understanding of process was “critical”, and that good communication and “an agreed protocol between primary care and the hospital laboratory” were necessary.

However, Professor Roche also made clear that digoxin was still an important “life-saving” drug.

He said that he did not want to people going to their doctor with "worry" about it, saying that patients who are on it for the long-term should have reviews, particularly as they age.

Earlier comments made by the GP suggested that there were sometimes issues with the logistics of requesting digoxin levels and timing it with when the patients take the drug.

He added that when he had raised this issue with the hospital following his patient’s death 2020, there had been no response from them.

It was noted by Mr Forder in the hearing that the hospital have updated their processes so that appointments and times are now booked through an electronic system, rather than people turning up on the day.

Concluding, the Deputy Viscount said that, in light of the evidence heard, he would be writing to highlight this case to the Primary Care directorate and the hospital, with a recommendation they take further action on digoxin monitoring.