Deceased
Leonard Athol Long
Demographics
73y, male
Date of death
2022-02-04
Finding date
2024-10-18
Cause of death
subdural haematoma from fall
AI-generated summary
Leonard Athol Long, a 73-year-old on warfarin for mechanical mitral valve replacement, fell twice during hospitalization for urinary tract infection. He was on SMZ-TMP antibiotics, which interact significantly with warfarin. After the first fall on 1 February, he had postural hypotension, mild head pain, and confusion, but the post-fall clinical pathway form was not properly completed and no CT brain was performed. A second fall occurred on 2 February without imaging. On 3 February, he deteriorated with altered consciousness and was found to have a massive acute subdural haematoma with herniation. The critical failure was non-completion of the standardized post-fall pathway, which would have triggered brain imaging. In elderly anticoagulated patients with head trauma, even minor head injury requires CT imaging due to risk of delayed bleeding. Early imaging would have allowed warfarin reversal and potentially different management. The case highlights failures in implementation of safety protocols, inadequate appreciation of consequences in an at-risk patient, and the need for standardized pathways in falls assessment.
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
74y · Male·small intestinal ischaemia caused by aortic atherosclerosis
A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…
65y · Male·Bleeding duodenal ulcer
A 65-year-old man with type 2 diabetes presented to hospital with haematemesis, hypoglycaemia, and postural hypotension caused by a bleeding duodenal ulcer. He was misdiagnosed with atypical pneumonia causing confusion. …
75y · Male·pneumonia and head injury from fall
Peter Harris, aged 75, was admitted with behavioural disturbance and hyponatraemia (low serum sodium of 124 mmol/L). Initial clinical assessment did not identify falls risk. After 4 days, he fell backwards suddenly while…
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