Deceased
Warren James Newell
Demographics
71y, male
Date of death
2022-10-01
Finding date
2024-09-30
Cause of death
raised intracranial pressure caused by left frontal-temporal-parietal subdural haemorrhage secondary to coagulopathy from supra-therapeutic enoxaparin dosing, previous rivaroxaban therapy, and dual antiplatelet agents
AI-generated summary
Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. However, he was prescribed an excessive dose of enoxaparin (100 mg twice daily) instead of the weight-appropriate dose of 70 mg twice daily. This supra-therapeutic anticoagulation, combined with rivaroxaban and dual antiplatelet agents, likely contributed to a catastrophic left frontal-temporal-parietal subdural haemorrhage that developed on 1 October 2022, resulting in death. Key preventable factors included failure to weigh the patient on admission, absence of electronic prescribing safeguards, and lack of pharmacist review. Implementation of weight-based dosing protocols, e-prescribing systems, and pharmacy services could have prevented this tragic outcome.
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
43y · Male·hypoxic brain injury caused by cardiac arrest due to unintentional drug poisonin…
A 43-year-old man with long-standing opioid use disorder and polysubstance dependence died from hypoxic brain injury following cardiac arrest caused by drug poisoning. He had been prescribed large quantities of pregabali…
82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…
Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …
86y · Male·progressive cognitive decline/decompensation and gastrointestinal haemorrhage
An 86-year-old man with Parkinson's disease and long-standing gastro-oesophageal reflux disease (GORD) sustained a traumatic brain injury from a fall at home on 3 July 2021. He was admitted to hospital on 6 July 2021 wit…
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.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.