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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. Report an inaccuracy.

Specialties

paramedicineemergency medicineneurosurgery

Error types

diagnosticcommunicationsystem

Drugs involved

warfarindigoxinmetoprolol

Clinical conditions

acute subdural haematomaminor traumatic brain injuryatrial fibrillationanticoagulation-related intracranial bleedingneurological deterioration

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

  1. Implement all recommendations contained in the Ambulance Tasmania Root Cause Analysis report dated 18 November 2020 within stated completion dates
  2. Develop formal guidance addressing clinical care and transportation of patients with minor head trauma
  3. Review paramedic education in neuro-assessment and mechanism of injury assessment, and consider developing in-field tools to guide practice
  4. Scope development of an early post-attendance call back process for patients in Patient Not Transported or Refused Treatment/Transport categories
  5. Develop and implement formal procedures addressing the distinction between Patient Not Transported and Refusal of Treatment/Transport concepts
  6. Review format and scope of clinical reviews conducted by Ambulance Tasmania Regional Training Units
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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