SA woman's death preventable: coroner

A woman who died after being placed on heart medication was not properly monitored and her death could have been prevented, a coroner has found.

Marjorie Irene Aston, 86, died in 2013 after suffering a severe head injury in a fall which proved fatal, largely because of the effects of the blood-thinning drug warfarin.

South Australian Deputy Coroner Anthony Schapel said Mrs Aston's blood levels had not been properly monitored and by the time she died her international normalised ratio (INR), a measure of how thin her blood had become, was life threatening.

"If her INR levels had been monitored in accordance with usual clinical requirements her warfarin dosages would have been adjusted," Mr Schapel said in his finding on Friday.

"Her death thereby would have been prevented."

Mr Schapel said the lack of monitoring was the result of a questionable reliance on Mrs Aston's ability to contact her GP after a specialist began her warfarin treatment and a lack of communication between the specialist and her general practitioner.

He has recommended those lines of communication be improved and has also suggested that when GPs are responsible for monitoring warfarin treatment, they should be the ones to administer the drug.