Coroner's Finding: STOCK Anthony Douglas

64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperitoneal and pelvic haemorrhage complicating pelvic fractures

A 64-year-old man died from hypovolaemic cardiac arrest caused by retroperitoneal bleeding from a pelvic fracture. The bleeding occurred six days post-injury while on high-dose enoxaparin (100mg twice daily) initiated under an orthopaedic protocol. Critical failings included: (1) no blood tests performed after admission to monitor haemoglobin or renal function despite therapeutic anticoagulation; (2) nursing staff ignored patient and family requests for medical review when signs of shock (pallor, clammy skin, diaphoresis) appeared at 3:30-4pm; (3) no doctor assessed the patient between 10:30am and his arrest at 10pm despite multiple requests; (4) the anticoagulation protocol itself was flawed, using full therapeutic rather than prophylactic dosing without clear indication. The coroner found the death was preventable—prompt medical assessment at 4pm would likely have identified shock, triggered investigations and supportive IV therapy, potentially preventing arrest. Key lessons: monitor anticoagulation with regular bloods; respond urgently to family concerns about clinical deterioration; ensure senior review of therapeutic-dose anticoagulation protocols.