THE sister of York City football coach Luther Blissett died from a reaction to a blood-thinning drug after being seen up to 16 times in hospital, an inquest heard.
A coroner recorded a verdict of death by misadventure on Carole Anne Blissett, 34, after hearing the mother of three was diagnosed with a blood clot on returning from Barbados last year.
She was given the anticoagulant warfarin, but suffered an adverse reaction and was switched to another drug, Phenindione. She died from multi-organ failure and pulmonary embolism.
It was discovered a nurse at the Central Middlesex Hospital had tested for liver function but the results were not considered. The coroner will write to the hospital about acting on information.
After the hearing, Luther Blissett said: "We're not surprised it was a misadventure verdict but we wanted to highlight the importance of keeping notes and passing them on."
Describing his sister as "bright and fun-loving" he said she was someone who would have done anything for anybody.
At the inquest on Ms Blissett, of Church Road, Willesden, Southwark, Coroner Dr Adele Williams said: "I'm satisfied on the balance of probability this was contributed to by the use of Phenindione."
Dr Nicola O'Brien, a doctor at the hospital, said she saw Ms Blissett when she complained of headaches and dizziness, pain and neck stiffness.
As the doctor was unfamiliar with her medication, Ms Blissett was referred to a medical registrar, but Dr O'Brien was not involved in further discussions.
She noticed from notes that Ms Blissett was prescribed paracetamol for pain relief.
Specialist registrar Dr William Strain saw her next day when she had flu-like symptoms. He said he did not ask for a liver function test and believed a triage nurse may have "ticked that box" or the test had been carried out in a batch.
"It's my responsibility to look at any tests I order, but I had not ordered this one."
Professor David Grahame-Smith, a Professor of Clinical Pharmacology, said the use of Phenindione was reduced in the 60s because of adverse reactions, but not many people would know about that now.
Updated: 11:52 Wednesday, July 17, 2002
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