Finding into death of Takashi Le Minh

34y · Male·Acute intracranial haemorrhage, malignant hypertension, renal artery stenosis

A 34-year-old man with malignant hypertension, prosthetic mitral valve, and renal artery stenosis died from acute intracranial haemorrhage while in prison custody. He presented with headache and hypertension on 13 June, was transferred to hospital, diagnosed with bilateral renal artery stenosis and two undiagnosed brain lesions, then returned to prison on 16 June. His anticoagulation management was complex; warfarin dosing was adjusted multiple times with subtherapeutic INR levels. On 24 June he developed severe headache, collapsed, and was found to have intracranial haemorrhage. The coroner found medical management appropriate including prompt hospital transfer, adequate follow-up arrangements, and responsive adjustment of anticoagulation. No preventable errors were identified.