Deceased
Ian Trengove
Demographics
81y, male
Date of death
2008-03-30
Finding date
2011-06-22
Cause of death
Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with contributing warfarin anticoagulation and ischaemic and hypertensive heart disease
AI-generated summary
An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of injury. Critical failures included: (1) no INR testing on emergency admission despite warfarin use—a routine test that would have revealed over-anticoagulation; (2) failure to recognize bleeding risk from minimally displaced pelvic fractures combined with excessive anticoagulation; (3) no medical review overnight despite deteriorating vital signs (hypotension, bradycardia, desaturation); and (4) misdiagnosis of dehydration/possible MI on morning review, without considering pelvic bleeding as the primary differential. A CT scan would likely have identified the bleeding. Expert opinion suggested survival was probable if bleeding had been identified and managed by morning, using anticoagulation reversal, transfusion, and ICU care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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