Source · Prevention of Future Deaths

Thelma Clarkson

Date: 27 Nov 2015 Coroner: David Horsley Area: Portsmouth and South East Hampshire Responses identified: 0 / 1 View PDF

The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. This omission can lead to missed diagnoses and delayed treatment.

Date 27 Nov 2015
56-day deadline 22 Jan 2016
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. This omission can lead to missed diagnoses and delayed treatment.
View full coroner's concerns
_ Prior to her fall, Mrs Clarkson has for some time been prescribed and was taking the drug Clopidogrel for her long-standing heart disease British National Formulary warns that patients taking Clopidogrel are at risk of increased bleeding from trauma. However , was told in evidence at the Inquest that under the NICE Head Injury Pathway which was in use at the time at Gosport War Memorial Hospital, had Mrs Clarkson been taking Warfarin she would have been sent to a larger hospital to have a CT scan of her head but the Pathway did not include Clopidogrel as a similar trigger for a CT scan notwithstanding the risk of increased bleeding head trauma: was also told that; had Mrs Clarkson been sent from Gosport War Memorial Hospital for a CT scan, there is strong_ possibility it would have revealed the extent of her head injury and her my War The The from treatment and its potential outcome may have been different: am therefore concerned that the NICE should consider whether its Head Injury Pathway should be amended to include taking Clopidogrel as a trigger for a CT scan in the same way as Warfarin presently does_

Report sections

Investigation and inquest
On 25"h February 2015 commenced an investigation into the death of Thelma Doris Clarkson. The investigation concluded at the end of the inquest on 1gth November 2015_ The conclusion of the inquest was: Mrs Clarkson's medical cause of death was Acute Subdural Haematoma and concluded that her death was due to an Accident: enclose a copy of Record of Inquest:
Circumstances of the death
On 10lh February 2015 Mrs Clarkson fell in her home. She sustained a number of injuries, including head injuries. She was taken to Gosport Memorial Hospital where her injuries were treated and she was discharged home that afternoon: Following her return home, her condition deteriorated and she was taken by ambulance that evening to Southampton General Hospital where examination determined she had sustained an inoperable head injury from her earlier fall. She died at Southampton General Hospital on 11 February 2015_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action.

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Report details

Date of report
27 November 2015
Coroner
David Horsley
Coroner area
Portsmouth and South East Hampshire

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: 22 Jan 2016.

Sent to

National Institute for Health and Care Excellence

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