Finding into death of Alexander Ignatius Cody
Deceased
Alexander Ignatius Cody
Demographics
93y, male
Date of death
2010-04-03
Finding date
2013-02-21
Cause of death
Intracranial haemorrhage in the setting of over-warfarinisation
AI-generated summary
A 93-year-old man on warfarin for atrial fibrillation sustained a head strike in a fall at residential aged care. Initial assessment by ambulance was appropriate and he was not transferred. Over subsequent days, neurological signs developed but were not escalated. INR testing was delayed (14 days without testing), and when finally checked, it was critically elevated at 10. Naproxen prescribed after the fall further increased warfarin effect. He developed intracranial haemorrhage and died. Key lessons: INR monitoring protocols must be robust with backup alerts if testing lapses; medication changes must be communicated to anticoagulation services; neurological deterioration in warfarin-treated patients requires urgent reassessment and imaging; aged care facilities need structured post-fall management for anticoagulated residents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Lapse in INR testing (14-day gap before fall)
- Critically elevated INR of 10 not detected until after neurological deterioration
- Prescription of Naproxen post-fall, which increases warfarin effect
- Fall with head strike in patient on anticoagulation not reported to pathology service
- Change in medication regime not communicated to pathology service
- No procedure in place to alert if INR testing routine was missed
- Neurological signs on 24 March (right-sided weakness) not escalated to hospital
- No structured post-fall management checklist for INR review in anticoagulated residents
Coroner's recommendations
- Lionsbrae Hostel to add 'INR review' to head injury post-fall management checklist for residents on anticoagulation medication
- Lionsbrae Hostel to have available observation charts and neurological charts for staff to record post-fall findings and put in place protocols to ensure findings are recorded
- Lionsbrae Hostel to put in place mechanism for reporting falls and/or resident's change of medication regime to the INR pathology service for consideration of rescheduling testing
- Lionsbrae Hostel to develop means by which alert is raised if resident's INR testing routine is not followed or appears to fall outside established pattern
Full text
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