Source · Prevention of Future Deaths
Selina Broadhurst
Ref: 2014-0065
Date: 17 Feb 2014
Coroner: John Pollard
Area: Manchester (South)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner raised concerns that NICE Guidelines for head CT scans, which require obvious neurological signs, may lead to missed or delayed diagnosis of severe brain injuries in frail elderly patients.
Date
17 Feb 2014
56-day deadline
14 Apr 2014
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner raised concerns that NICE Guidelines for head CT scans, which require obvious neurological signs, may lead to missed or delayed diagnosis of severe brain injuries in frail elderly patients.
View full coroner's concerns
The Emergency Department doctors indicated that they could not get a CT of the head because "the NICE Guidelines do not indicate as appropriate where there are no obvious neurological signs have noted in this inquest and indeed in a number of inquests previously that the doctors are following these guidelines and in fact many severe brain injury cases are being missed or there is a delay in diagnosis. Is it not now time that this guideline was re-examined and the advice amended, especially when dealing with the very frail elderly patient?
Report sections
Investigation and inquest
On 21st February 2013 commenced an investigation into the death of Selina Isabella Broadhurst dob 1st January 1927 . The investigation concluded on the12th February 2014 the conclusion was one of Accidental Death. The medical cause of death was 1a Bronchopneumonia 1b Intra-cerebral Haemorrhage 2 Vascular dementia and Type two diabetes mellitus CIRCUMSTANCES OF THE DEATH: On the 14th February 2013 she fell at the EP.H. where she lived and suffered a blow to the head. She was admitted to hospital and, inter alia, she was not afforded a CT scan of her head until a second admission some hours later when she was shown to have a major bleed to the brain: This was despite the fact that she had an external injury to the front of her scalp
Action should be taken
In my opinion action should be taken to prevent future deaths and believe_You_have and and being the power to take such action: It is essential that full information is passed promptly to the GP practice of a patient being discharged:
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Report details
- Reference
- 2014-0065
- Date of report
- 17 February 2014
- Coroner
- John Pollard
- 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: 14 Apr 2014 (stated in the report).
Sent to
- National Institute for Health and Care Excellence