Robert Goodman
15 Dec 2020 · Coroner Jason Pegg · Hampshire, Portsmouth and Southampton
The coroner's concerns
1. delayed head injury assessment
“The Trust policy is said to reflect the National Institute for Health and Care Excellence guidance on the assessment and early management of head injuries”
2. inadequate scan timing for anticoagulated patients
“The present Trust policy states that a computerised tomography scan of the head should be undertaken within 8 hours of the injury if a patient is receiving anticoagulant treatment”
3. lack of awareness of updated guidance
“The Trust were not aware of the September 2019 variation in National Institute for Health and Care Excellence guidance which now advises that patients who are on any anticoagulant should have a computerised tomography scan within 8 hours of a head injury”
4. scan performed 30 hours post-injury
“The deceased's computerised tomography scan was undertaken 30 hours after the deceased had suffered a head injury”