Source · Prevention of Future Deaths
Lucy Kilvert
Ref: 2013-0266
Date: 21 Oct 2013
Coroner: Robin John Balmain
Area: Black Country
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted a delay in performing a CT scan of the head for Mrs. Kilvert and raised concerns that NICE Guidelines may insufficiently emphasise the significance of blood-thinning medication in elderly patients who have fallen when considering a CT scan.
Date
21 Oct 2013
56-day deadline
12 Feb 2014 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner noted a delay in performing a CT scan of the head for Mrs. Kilvert and raised concerns that NICE Guidelines may insufficiently emphasise the significance of blood-thinning medication in elderly patients who have fallen when considering a CT scan.
View full coroner's concerns
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A.M. CORONER 21 October 2013 Continuation , namely that Mrs. Kilvert was not initially at the hospital given CT scan of the head. It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was la) Intracranial bleed, Chronic Kidney Failure Hypertension Heart Valve Replacement: As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect bleed, although the consultant said that his judgment may have been different The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had had a fall when considering whether CT scan of the head was necessary, albeit that eventually the matter was a question of clinical judgment
A.M. CORONER 21 October 2013 Continuation , namely that Mrs. Kilvert was not initially at the hospital given CT scan of the head. It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was la) Intracranial bleed, Chronic Kidney Failure Hypertension Heart Valve Replacement: As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect bleed, although the consultant said that his judgment may have been different The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had had a fall when considering whether CT scan of the head was necessary, albeit that eventually the matter was a question of clinical judgment
Report sections
Investigation and inquest
On 19th June 2013 commenced an investigation into the death of KILVERT. The investigation concluded at the end of the inquest on 16th October 2013. The conclusion of the inquest was that death was due to an accident:
Circumstances of the death
The deceased was taken to hospital on 14th June 2013 having suffered fall at home on 10th June 2013 and subsequently deteriorating: She had hit her head in the fall and was on blood thinning medication. She was 84 at the time
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action I would respectfully invite you to consider whether further consideration of the Guidelines is appropriate
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Report details
- Reference
- 2013-0266
- Date of report
- 21 October 2013
- Coroner
- Robin John Balmain
- Coroner area
- Black Country
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: 12 Feb 2014 (estimated from the Judiciary.uk publication date).
Sent to
- National Institution for Health and Clinical Excellence