Coroner calls for protocol change

ALL Tasmanian hospitals need to develop a reverse anticoagulation protocol, a coroner has recommended after the death of an elderly woman who had hit her head.

Coroner Simon Cooper said such a protocol, like those developed in the Queensland and NSW health systems, would ensure the need to reverse the effects of blood thinning medication was considered and acted upon in appropriate cases.

Mr Cooper made the recommendation in his findings into the death of Eva Fay Davis, who suffered a closed head injury after tripping on a power cord.

Mrs Davis was first admitted to the Mersey Community Hospital before dying in the Royal Hobart Hospital on December 22, 2017.

Coroner Cooper said a failure to reverse her anti-coagulant had not caused or contributed to her death.

“However, I still consider it necessary to highlight the issue of reversal of anti-coagulation so as to potentially prevent future deaths,” he said.

Ten days before she died, the 87-year-old had tripped over an electric cord at her home, fell, hit her head and suffered a nosebleed.

She activated her personal alarm. Ambulance Tasmania attended and transported her to the MCH.

An urgent CT scan of her brain was performed which showed she had suffered a subdural haematoma.

After consultation with the neurosurgical registrar at the RHH a decision was made to observe Mrs Davies in hospital and repeat the CT scan of her brain in 24 hours.

However, her condition deteriorated and she was transported to the RHH for urgent neurosurgery.

Mrs Davies did not wake up after surgery.

After family discussion all active treatment was ceased and palliative care began.

“In my view, given the fact that Mrs Davies was on irreversible anti-coagulation and had been identified as suffering from acute subdural haematoma she should have been urgently transferred to a neurosurgical facility,” Coroner Cooper said.

“Finally, I note that Mrs Davies’ medical records indicate that staff at the MCH, recognising the significance of the issue, sought urgent advice of a haematological registrar at the Launceston General Hospital, rather than the consultant haematologist on call at the MCH.”