Finding into death of Ian Lindsay Gould

64y · Male·Complications of Creutzfeldt-Jakob Disease following a fall

Ian Gould, a 64-year-old man with a non-MRI compatible pacemaker, presented with vision loss in June 2019. Initial neurological and ophthalmological evaluation was normal; functional visual loss was suspected. He developed major depression with suicidal ideation and was admitted to an acute mental health unit. On 7 August, he fell backwards, hitting his head, but was assessed as orientated with no bruising. No CT scan was performed despite being on anticoagulation (rivaroxaban). Over subsequent days he deteriorated with stiffness, fever, and decreased consciousness. Transfer to ICU revealed bilateral occipital haemorrhage on CT, status epilepticus on EEG, and ultimately sporadic Creutzfeldt-Jakob Disease (CJD) confirmed by lumbar puncture and brain biopsy. The coroner found that while BHS head injury guidelines did not reflect current standard practice recommending CT scans for anticoagulated patients with head strikes, earlier imaging would not have altered the outcome as his deterioration was due to CJD, not the modest intracerebral bleed. The death was not preventable.