Coroner's Finding: Newell, Warren James

71y · Male·raised intracranial pressure caused by left frontal-temporal-parietal subdural haemorrhage secondary to coagulopathy from supra-therapeutic enoxaparin dosing, previous rivaroxaban therapy, and dual antiplatelet agents

Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. However, he was prescribed an excessive dose of enoxaparin (100 mg twice daily) instead of the weight-appropriate dose of 70 mg twice daily. This supra-therapeutic anticoagulation, combined with rivaroxaban and dual antiplatelet agents, likely contributed to a catastrophic left frontal-temporal-parietal subdural haemorrhage that developed on 1 October 2022, resulting in death. Key preventable factors included failure to weigh the patient on admission, absence of electronic prescribing safeguards, and lack of pharmacist review. Implementation of weight-based dosing protocols, e-prescribing systems, and pharmacy services could have prevented this tragic outcome.