Linda Lloyd

On 10th January 2014 an investigation commenced into the death of Linda Rose Lloyd aged 63 years. The investigation concluded at the end of the inquest heard on 1st April and 28th August 2014.

The record of the inquest confirmed as follows:

The Medical cause of death was Ia Acute subdural haemorrhage

The conclusion of the Coroner as to the death was Narrative conclusion as follows:

Having complained of a headache earlier that morning, on 2nd January 2014 Linda Rose Lloyd was found at her home address at 19:14 hours with a Glasgow coma score of 10/15 and unable to verbally respond to ambulance personnel. She was taken to hospital where she was triaged and assessed as being a very urgent priority. She was not assessed by a doctor until 22:12 hours and noted to have a Glasgow coma score of 7/15. A CT scan was undertaken at 01:15 hours the following morning which confirmed the presence of an acute subdural haemorrhage. She was not felt to be suitable for neurosurgical intervention and was pronounced deceased at 19:55 hours on 3rd January 2014. There was a delay in treatment which could have affected the outcome.

See the contents of section 3 above. The inquest was informed that at the time of Mrs. Lloyd’s attendance at the hospital her triage assessment was undertaken by a junior paediatric staff nurse, and that these nurses were sometimes utilised to provide cover in the ambulance triage area when staff shortages ensued. Further, that although Mrs. Lloyd was triaged correctly, that the inexperience of the nurse meant that information that the patient was a very urgent priority was not passed on to either the nursing staff for the relevant area or a senior doctor and so was not acted upon as an emergency.

The inquest was told by an independent Consultant in Accident and Emergency Medicine that given the patient was suffering from a time critical lesion any delays in assessment, diagnosis and treatment must be regarded as contributory factors to a poor outcome and that certain aspects of her care could and should have been addressed more promptly in terms of:

 Medical assessment within 10 minutes of triage;  Initial neurological observations including assessment of pupils and Glasgow Coma Score, plus ongoing regular monitoring of her neurological state starting with every 10 to 15 minutes;  A more immediate response to a history of warfarin use and findings of a raised INR requiring treatment;  CT scanning of the head should have taken place as soon as possible after arrival and certainly within one hour of arrival;  Earlier discussion with the Neurosurgical team.

The Consultant further informed the inquest that having triaged the patient and designated her as a “very urgent” priority and then doing nothing about it was completely unacceptable. He added that it is also unacceptable that it was over two hours before Mrs. Lloyd had a second GCS score recorded by an examining doctor and that there was then a further long delay before a GCS score was taken again and recorded on an observation chart. Also, he felt there too long a delay in administering drugs to reverse the effect of warfarin therapy in someone who was actively bleeding.

He concluded that it is vital that the Trust undertake a review of this case to address these areas to ensure that any future patients with time critical neurosurgical lesions have prompt assessment, investigation, referral and transfer to optimise the potential for a better outcome.

Having complained of a headache earlier that morning, on 2nd January 2014 Linda Rose Lloyd was found at her home address at 19:14 hours with a Glasgow coma score of 10/15 and unable to verbally respond to ambulance personnel. She was taken to hospital where she was triaged and assessed as being a very urgent priority. She was not assessed by a doctor until 22:12 hours and noted to have a Glasgow coma score of 7/15. A CT scan was undertaken at 01:15 hours the following morning which confirmed the presence of an acute subdural haemorrhage. She was not felt to be suitable for neurosurgical intervention and was pronounced deceased at 19:55 hours on 3rd January 2014. There was a delay in treatment which could have affected the outcome.