Deceased
Carl David Waldon
Demographics
64y, male
Coroner
Coroner Audrey Jamieson
Date of death
2019-07-24
Finding date
2021-02-05
Cause of death
Left-sided intracerebral haemorrhage associated with deep brain stimulator wire tract
AI-generated summary
A 64-year-old man died from intracerebral haemorrhage along a deep brain stimulator wire tract four days after elective neurosurgery for essential tremor. He was readmitted on day 4 with suspected stroke and started on therapeutic anticoagulation (enoxaparin). A haemorrhage developed within 24 hours of dose escalation. Key clinical failures: the prescribed enoxaparin dose (120mg twice daily) exceeded the guideline-recommended dose for his lean body weight (107mg twice daily); antiXa levels were not checked at appropriate timepoints to verify therapeutic range; specialist haematology oversight was not obtained despite obesity and renal impairment making enoxaparin pharmacokinetics unpredictable. An alternative strategy—delaying DBS until a Watchman device insertion for atrial fibrillation—was identified but not pursued. Clinicians should calculate anticoagulation doses by lean body weight in obese patients, obtain specialist oversight for complex cases, and monitor antiXa levels appropriately.
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
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66y · Male·Intracerebral haemorrhage
A 66-year-old man with intracerebral haemorrhage and concurrent deep vein thrombosis died following an accidental tenfold heparin overdose. The patient received 20,000 units instead of 2,000 units due to a nurse misreadi…
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