Coroner's Finding: TRENGROVE Ian

81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with contributing warfarin anticoagulation and ischaemic and hypertensive heart disease

An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of injury. Critical failures included: (1) no INR testing on emergency admission despite warfarin use—a routine test that would have revealed over-anticoagulation; (2) failure to recognize bleeding risk from minimally displaced pelvic fractures combined with excessive anticoagulation; (3) no medical review overnight despite deteriorating vital signs (hypotension, bradycardia, desaturation); and (4) misdiagnosis of dehydration/possible MI on morning review, without considering pelvic bleeding as the primary differential. A CT scan would likely have identified the bleeding. Expert opinion suggested survival was probable if bleeding had been identified and managed by morning, using anticoagulation reversal, transfusion, and ICU care.