Coroner's Finding: Phillips, Helen Lynette
Deceased
Helen Lynette Phillips
Demographics
77y, female
Date of death
2022-12-21
Finding date
2025-03-17
Cause of death
intracranial haemorrhage (subdural, intraventricular and brainstem)
AI-generated summary
A 77-year-old woman fell from a ladder on 12 December 2022, suffering loss of consciousness and rib fractures. No brain CT scan was performed at Mersey Community Hospital despite the mechanism of injury and unconsciousness suggesting head trauma risk. Eight days later, she suffered a STEMI and received thrombolysis based on standard protocols. However, she likely had a small intracranial haemorrhage from the initial fall. Thrombolysis is contraindicated with prior ICH. The clot-dissolving therapy caused expansion of the existing bleed, leading to fatal subdural, intraventricular, and brainstem haemorrhages. The critical clinical lesson: elderly patients with significant falls and loss of consciousness warrant brain imaging regardless of absent neurological signs, as ICH symptoms may be silent and imaging results would have prevented fatal thrombolysis.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- failure to perform head CT scan at Mersey Community Hospital following fall with loss of consciousness
- undiagnosed intracranial haemorrhage from initial fall
- thrombolysis administered in presence of prior ICH (absolute contraindication)
- expansion of pre-existing ICH due to thrombolytic therapy
- elderly patient with silent ICH symptoms
Coroner's recommendations
- MCH ought to have in place written procedures requiring CT scanning of the brain in circumstances of a fall of some force and loss of consciousness, regardless of the absence of overt signs and symptoms of head injury
- Protocols should be established to ensure that elderly patients presenting with a history of fall and loss of consciousness receive consideration for brain CT scanning
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