Coroner's Finding: Bowerman, Valerie Joy
Deceased
Valerie Joy Bowerman
Demographics
80y, female
Date of death
2017-09-12
Finding date
2021-05-06
Cause of death
acute subdural haematoma following a fall while on warfarin for atrial fibrillation
AI-generated summary
Mrs Bowerman, aged 80, fell at home on warfarin anticoagulation and sustained a minor head injury with no initial neurological signs. Paramedic Turnbull assessed her as requiring no transport (TNR), despite her anticoagulant use. She deteriorated neurologically 4 hours later with massive subdural haematoma, dying 3 days post-admission. The coroner found Turnbull should have more actively conveyed the urgency of hospital transport, particularly given her warfarin use and age. Key systemic issues included: lack of formal training on anticoagulated head injury patients, confusion between TNR and transport-refused policies, and absence of specific clinical guidelines. Even with early transport, prognosis remained poor but a 2-4 hour intervention window existed. The coroner endorsed RCA recommendations for formal guidance, improved paramedic education on mechanism of injury assessment, and clarification of transport decision policies.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- failure to appreciate risk of intracranial haemorrhage in elderly patient on anticoagulation with minor head trauma
- inadequate communication to patient and daughter regarding urgency of hospital assessment
- TNR documentation suggesting paramedic underestimated clinical risk
- lack of formal training on anticoagulated patients with head trauma
- absence of specific clinical guidelines for falls with head strike in anticoagulated patients
- patient's firm refusal of hospital transport
- delayed recognition of neurological deterioration at home
- lucid interval masking severity of injury
Coroner's recommendations
- Implement all recommendations contained in the Ambulance Tasmania Root Cause Analysis report dated 18 November 2020 within stated completion dates
- Develop formal guidance addressing clinical care and transportation of patients with minor head trauma
- Review paramedic education in neuro-assessment and mechanism of injury assessment, and consider developing in-field tools to guide practice
- Scope development of an early post-attendance call back process for patients in Patient Not Transported or Refused Treatment/Transport categories
- Develop and implement formal procedures addressing the distinction between Patient Not Transported and Refusal of Treatment/Transport concepts
- Review format and scope of clinical reviews conducted by Ambulance Tasmania Regional Training Units
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