Finding into death of Jean Elizabeth Crocker

Contributing factors

• Failure to detect small subdural haemorrhage on initial CT brain imaging
• Prescription of enoxaparin (LMWH) to patient already therapeutically anticoagulated with warfarin
• Failure to reverse warfarin after fall with head strike
• Failure to consider intracranial bleeding risk when planning anticoagulation for suspected NSTEMI
• Inadequate medication reconciliation and communication between pharmacy and medical staff
• Multiple failed clinical handovers that did not communicate anticoagulation status
• Inadequate Post Falls Response and Management Guideline
• Electronic prescribing system did not alert to dual anticoagulation
• Lack of senior review of decision to add anticoagulation given recent head trauma

Coroner's recommendations

1. Review Post Falls Response and Management Guideline to include specific instructions regarding performance of a clotting profile for patients presenting with a fall with head strike
2. Implement a routine alert in all relevant areas (EMR, handover, prescribing) that a patient is therapeutically anticoagulated
3. Review handover process to include an ISBAR (Identify, Situation, Background, Assessment and Recommendation) style format that always includes patient alerts, including anticoagulation
4. Implement a requirement that the pharmacist performing medication reconciliation communicate the pertinent findings of the reconciliation directly to the responsible doctor
5. Introduce an alert in the Electronic Medical Records system that is triggered when two different anticoagulant medications are entered into the medication management system, regardless of whether the medications are prescribed during admission or recorded as home medications