Inquest into the death George TRIANTAFILOPOULOS

75y · Male·acute right subdural haemorrhage sustained in a fall

George Triantafilopoulos, a 75-year-old man on warfarin after aortic valve replacement, suffered two head strikes within 24 hours—first falling onto concrete at a supermarket on 14 August 2014, then falling onto concrete at a shopping centre on 15 August 2014. Both times he was assessed by GPs who performed neurological examinations, found GCS 15, and discharged him home with observation instructions. Neither GP ordered a CT brain scan despite the high-risk combination of age, anticoagulation, and head trauma. By 3pm on 15 August, George developed altered consciousness and vomiting. He was admitted with a massive right subdural haemorrhage and died the next morning. The coroner found both GPs provided adequate care under circumstances, but noted in retrospect a more conservative approach referring to hospital would have been reasonable. The case highlights the clinical challenge of identifying intracranial bleeding in anticoagulated elderly patients presenting with apparently normal neurological findings, and the importance of considering cumulative head trauma risk.