Deceased
Mary Veronica Levin
Demographics
77y, female
Coroner
Coroner Rosemary Carlin
Date of death
2014-08-02
Finding date
2016-06-30
Cause of death
Subdural haematoma secondary to blunt head trauma (head-strike)
AI-generated summary
A 77-year-old woman on warfarin for atrial fibrillation presented to Sandringham Hospital after striking her head on a wall. Despite being on anticoagulation therapy, no CT scan was performed, and she was discharged after wound closure. She died 26 hours later from a massive subdural haematoma. Alfred Health had a specific guideline requiring CT imaging and admission for anticoagulated patients with head trauma. The consultant claimed unawareness of her warfarin use, though the registrar reported informing him. The hospital failed to follow its own guideline. While the coroner could not establish that guideline adherence would have prevented death, the failure deprived the patient of her only chance of survival. Key lessons: never assume minor head injury presentation excludes intracranial bleeding in anticoagulated patients; ensure senior clinicians are aware of medication history; follow institutional guidelines; and establish facts rather than attributing failures to communication breakdown.
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
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