Source · Prevention of Future Deaths
Colin Bailey
Ref: 2019-0106
Date: 29 Mar 2019
Coroner: Christopher Murray
Area: Manchester (South)
Responses identified: 0 / 1
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National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their necessity.
Date
29 Mar 2019
56-day deadline
4 Aug 2019 est.
Responses identified
0 of 1
Coroner's concerns
National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their necessity.
View full coroner's concerns
The inquest heard that Mr Bailey fell and hit his head whilst an in-patient at Stepping Hill hospital. No CT scan of the brain/head was undertaken despite Mr Bailey taking anti-coagulant medication because NICE guideline recommend a scan is undertaken if the patient has fallen, struck their head and is taking warfarin but that is not the guidance if the anticoagulant medication is one of the other types of anticoagulant medications used. The clinicians attending the Inquest indicated that a CT scan in this scenario should be undertaken whatever the type of anti-coagulant medication and that is the Trust's own policy going forwards: There was concern that this ought to be national guidance:
Report sections
Investigation and inquest
On 11th April 2018 an investigation into the death of Colin Bailey was commenced and an inquest opened on 19ih April 2018. The Inquest was concluded on 1gth March 2019 and the conclusion was one of Narrative: Mr Bailey died as a result of a recognised risk of the use of anti-coagulant medication in combination with his cO-morbid conditions The medical cause of death was Ia Extensive subarachnoid haemorrhage bilaterally with intraventricular extension of bleed: 1b Hypertension II Ischaemic stroke, atrial fibrillation requiring anti-coagulation, type 2 diabetes.
Circumstances of the death
Mr was admitted to Stepping Hill Hospital following a stroke on 9th March 2018. He was transferred to Tameside General Hospital on 14th march 2018 to continue his rehabilitation. On 1Oth April 2018 his condition suddenly deteriorated. A CT scan of the head showed an extensive subarachnoid haemorrhage bilaterally with intraventricular extension of the bleed which was linked to and probably exacerbated by the use of anticoagulant medication His health worsened and a as result of the subarachnoid haemorrhage he died at Tameside General Hospital Bailey -
on 1Oth April 2018.
on 1Oth April 2018.
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Report details
- Reference
- 2019-0106
- Date of report
- 29 March 2019
- Coroner
- Christopher Murray
- Coroner area
- Manchester (South)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Aug 2019 (estimated).
Sent to
- N.I.C.E