Finding into death of Alexander Ignatius Cody

93y · Male·Intracranial haemorrhage in the setting of over-warfarinisation

A 93-year-old man on warfarin for atrial fibrillation sustained a head strike in a fall at residential aged care. Initial assessment by ambulance was appropriate and he was not transferred. Over subsequent days, neurological signs developed but were not escalated. INR testing was delayed (14 days without testing), and when finally checked, it was critically elevated at 10. Naproxen prescribed after the fall further increased warfarin effect. He developed intracranial haemorrhage and died. Key lessons: INR monitoring protocols must be robust with backup alerts if testing lapses; medication changes must be communicated to anticoagulation services; neurological deterioration in warfarin-treated patients requires urgent reassessment and imaging; aged care facilities need structured post-fall management for anticoagulated residents.