Source · Prevention of Future Deaths

Phyllis Barlow

Ref: 2015-0027 Date: 29 Jan 2015 Coroner: Christopher Woolley Area: Cardiff & Vale of Glamorgan Responses identified: 1 / 1 View PDF

Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for CT scans as required.

Date 29 Jan 2015

56-day deadline 26 Mar 2015

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for CT scans as required.

View full coroner's concerns

The MATTER OF CONCERN is as follows. –

(1) At the time of her fall in the GP car park on 29th September 2014 NICE guidelines (on head injuries) were in place to the effect that anyone suffering a head injury who was on warfarin should be admitted to hospital forthwith and undergo a CT scan. who appeared at the inquest on behalf of the GP practice testified that these NICE guidelines were not known or appreciated by her GP practice at the time even though they were in force. Mrs Barlow was not admitted to hospital as she should have been on 29th September 2014. subsequent enquiries have revealed that there is widespread ignorance of these NICE guidelines among GP colleagues, although they are appreciated by the ambulance service, and A&E departments.

The Coroner is concerned that steps should be taken to make GP surgeries in Wales aware of the importance of these NICE guidelines, and that anyone who suffers a head injury while being treated with Warfarin should be admitted to hospital forthwith and a CT scan undertaken on them..

Responses

1 respondent

NHS Wales NHS / Health Body

9 Mar 2015 PDF

Action Planned

Welsh Government officials are developing a Patient Safety Notice to raise awareness of NICE guideline 176 regarding head injuries in patients on warfarin, which will be issued to all local health boards and general practices in Wales. Full compliance with the notice is expected within a month of circulation and will be monitored. (AI summary)

View full response

Dear Mr Woolley

Regulation 28 Report to prevent future deaths

I am writing to you in response to your Regulation 28 report of the 29th January 2015. In this report, you raise your concerns in regards to the awareness of NHS Wales staff of National Institute for Health and Care Excellence (NICE) guidance on head injuries.

NICE clinical guideline 176 refers to the care patients, who are having warfarin treatment, should receive following a head injury. The guideline states -

For patients (adults and children) who have sustained a head injury with no other indications for a CT head scan and who are having warfarin treatment, perform a CT head scan within 8 hours of the injury.

A lack of awareness of this important guideline is apparent from the detail of your report. In response to your concerns, Welsh Government officials are in the process of developing a Patient Safety Notice which will be issued to all local health boards and general practices in Wales.

The notice will be issued shortly and will raise awareness of the importance of this NICE guideline. Full compliance with this notice will be expected within a month of the notice being circulated and will be monitored.

Report sections

Investigation and inquest

On 12th November 2014 I commenced an investigation into the death of Phyllis Eleanor Barlow aged 83. The investigation concluded at the end of the inquest on 29th January 2015. The medical cause of death was: 1A Subdural haemorrhage (operated) and 2. Fracture left neck of femur (operated), Deep vein thrombosis (fully anti-coagulated), and the conclusion of the inquest was a narrative conclusion as follows: “Phyllis Eleanor Barlow died on the 8th November 2014 from a subdural haemorrhage sustained after a fall at home on the 30th September 2014. It is likely that the fall and her death were contributed to by significant natural disease and the appropriate medication given for it.”

Circumstances of the death

Phyllis Barlow was on a variety of medication for her existing co-morbidities, including warfarin to treat a deep vein thrombosis. On 29th September 2014 she fell in the GP surgery car park striking her head. She was treated for a minor abrasion and her observations were all normal. She went home after this without any difficulty. On 30th September 2014 she fell and struck her head at home, causing a subdural haemorrhage and fracturing her hip. She was taken to hospital where she was treated appropriately but died on 8th November 2014.

Copies sent to

2. , Deputy CMO Welsh Government

Inquest conclusion

“Phyllis Eleanor Barlow died on the 8th November 2014 from a subdural haemorrhage sustained after a fall at home on the 30th September 2014. It is likely that the fall and her death were contributed to by significant natural disease and the appropriate medication given for it.”

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Shared signals

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Report details

Reference: 2015-0027
Date of report: 29 January 2015
Coroner: Christopher Woolley
Coroner area: Cardiff & Vale of Glamorgan

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 Mar 2015.

Sent to

NHS Wales

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.