Deceased
Mary Weir
Demographics
80y, female
Date of death
2014-09-06
Finding date
2015-09-07
Cause of death
subdural haematoma due to closed head injury sustained in a fall from bed in hospital
AI-generated summary
An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no injury had occurred and no CT scan was performed. Two days later, when the patient became unresponsive, she was treated with a full dose of anticoagulant (Clexane) based on presumed stroke without first performing a plain CT scan to exclude intracranial bleeding. This violated basic medical principles. The subdural haematoma that developed was significantly worsened by the anticoagulation, causing seizures and deterioration. The coroner found the decision to anticoagulate without imaging was unsound practice and directly contributed to her death. Key lessons: always perform plain CT before anticoagulation in patients with recent falls; involve appropriate specialists in major treatment decisions; maintain high clinical suspicion for head injury in elderly patients on antiplatelet agents.
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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