Coroner's Finding: Long, Leonard
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.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- failure to complete post-fall clinical pathway form
- failure to perform CT brain imaging after falls in anticoagulated patient
- over-anticoagulation with warfarin (elevated INR)
- drug interaction between warfarin and SMZ-TMP not adequately managed
- postural hypotension not adequately addressed
- delayed recognition of subdural haematoma
- normal neurological examination falsely reassuring in elderly patient with brain atrophy
- lack of appreciation of consequences of falls in at-risk patient
- ward round failure to follow up on fall
- vitamin K prescribed but not documented as administered
Coroner's recommendations
- The inpatient post-fall clinical pathway form must be fully implemented by THS
- Medical staff must complete the post-fall clinical pathway form each time an inpatient suffers a fall
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