An 87-year-old woman with dementia, hypertension, and DVT died from acute intracranial haemorrhage while an inpatient at a general hospital under a Mental Health Act detention order. She was on warfarin for DVT management when she collapsed. A CT head scan was performed but images could not be viewed due to a GE systems outage, and she died before imaging results were available. The coroner found her medical care adequate and noted that any delay in diagnosis was immaterial given her resuscitation status (no CPR, no intubation). Her INR at time of collapse was subtherapeutic (1.9), making warfarin an unlikely contributor. The coroner identified no preventable factors or recommendations for improvement.
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