Recurring concern

Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries

First to latest report 31 Oct 2013 — 26 Jun 2026

Reports that mention this concern
28
Times this concern has been raised
33
Stated actions linked to this concern
46

What this concern includes

Includes deficiencies in dedicated head injury assessment or treatment pathways and their controls, including clinical decision support, triage, referral, escalation, admission, guidance, policy alignment and discharge arrangements, when they affect recognition or management of head injuries.

What is not included
  • Excludes generic staffing, training, documentation or communication deficiencies not explicitly tied to the head injury assessment or treatment pathway.
  • Excludes unrelated injury, falls, anticoagulation, emergency transport or clinical governance concerns unless they specifically concern recognition or management of a head injury.
  • Excludes deficiencies in pathways for other conditions, even where the failure mechanism is similar.

Reports and published responses 28 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Black Country

    AI-generated summary

    Edna May Davenport · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a clear head-injury management policy

    Wider context from the report

    “(7) No further checks were carried out by the home manager after this time and it appeared that evidence of the deceased becoming unwell and suffering with episodes of drowsiness were not recorded or indeed reported by staff caring for her. I am concerned that Oak Court does not have a clear policy in place to manage head injuries; ”

    Source location

    Edna May Davenport · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide and adjust neurological observations after head injury

    Wider context from the report

    “(5) I heard evidence that there were obvious signs of an injury to Edna’s head in the form of the injury to her eye which resulted in bruising and swelling. There was also evidence that the deceased had been punched to the head. The District Nurse recorded that Edna had had a headache and the deceased had complained to her daughter about suffering with a headache shortly after the assault. Despite this, no neuro observations were undertaken and there was no change to the frequency of Edna’s observations; ”

    Source location

    Edna May Davenport · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Hertfordshire

    AI-generated summary

    Tillie SPENCER-ADAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Tillie Spencer-Adams was found unresponsive in her mother's bed on 18 June 2018 and could not be resuscitated. The medical cause of death was unascertained, with the inquest concluding Sudden Unexpected Death in Infancy. The report identified concern that injuries potentially sustained in a road traffic collision, including fractures and head injuries, may have been overlooked when she attended hospital on 4 May 2018.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to identify serious injuries following road traffic collisions

    Wider context from the report

    “(1) On the 4/5/18 the deceased attended the Lister Hospital following a road traffic collision in which she is likely to have suffered serious injuries (fractures and head injuries) which appear to have been overlooked. ”

    Source location

    Tillie SPENCER-ADAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the care provided on 4 May 2018.

    Verbatim wording from the response

    “The contents of your letter were of grave concern to me and therefore I asked ████████ Clinical Director for Paediatrics, to review the care provided when Tillie attended on 4th May 2018.”

    Source location

    2019-0356-Response-by-East-and-North-Hertfordshire-NHS-Trust
    Page 1 · response
    Published 22 November 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Clinical findings did not require head or forearm imaging; assessment and national guidance supported no further investigation.

    Verbatim wording from the response

    “Whilst the triage nurse in ED noted a red mark on Tillie’s head, this was not observed by either the Paediatric doctors who reviewed her, nor any of the Paediatric nurses. In addition, Tillie did not exhibit any red-flag symptoms indicative of a head injury. Thus, in line with NICE Guidance, there was no indication to perform a CT head scan. Equally there were no external signs of any injury to her right forearm, nor did Tillie appear to be in any discomfort whilst in ED or the Paediatric unit. She did not require any analgesia and the medical records indicate that she was settled throughout.”

    Source location

    2019-0356-Response-by-East-and-North-Hertfordshire-NHS-Trust
    Page 2 · response
    Published 22 November 2019

    Open published response

  3. West Sussex

    AI-generated summary

    James William Francis · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    NICE guidelines inadequately addressing slow intracranial bleeding after falls in elderly patients

    Wider context from the report

    “The suggestion was that the existing guidelines may not sufficiently address the fact that this type of slow bleed fall in the elderly also needs to be considered i.e non-traumatic head injury leading to a shearing effect on the brain. The suggestion was that this type of slow bleed may take significantly longer to manifest in terms of observable symptoms such as a change in alertness or persistent vomiting. It certainly seems that the care home staff did not make the connection As a result, this raises concerns as to whether this type of incident which must be frequent in the elderly is adequately taken into account in relevant NICE guidelines ”

    Source location

    James William Francis · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct the ongoing surveillance review of the head injury guideline to determine whether it requires updating.

    Verbatim wording from the response

    “The guideline is currently undergoing a surveillance review exercise to determine whether it should be updated. As a result of your report, the review is likely to conclude that an update is required so that it is clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users). A final surveillance review decision is due to be published in September 2019.”

    Source location

    2019-0202-Response-by-NICE
    Page 1 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish the final surveillance review decision in September 2019.

    Verbatim wording from the response

    “The guideline is currently undergoing a surveillance review exercise to determine whether it should be updated. As a result of your report, the review is likely to conclude that an update is required so that it is clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users). A final surveillance review decision is due to be published in September 2019.”

    Source location

    2019-0202-Response-by-NICE
    Page 1 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NICE guidelines do not apply to the organisation, so it will not undertake work to address their adequacy.

    Verbatim wording from the response

    “6) Adequacy of NICE guidelines - which do not apply to ourselves, we note that a response is required from the Chief Executive of NICE. We will of course fully work to any revisited set of NICE guidelines.”

    Source location

    2019-0202-Response-by-Shaw-Healthcare
    Page 1 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Chief Executive of NICE is responsible for responding to concerns about the adequacy of NICE guidelines.

    Verbatim wording from the response

    “6) Adequacy of NICE guidelines - which do not apply to ourselves, we note that a response is required from the Chief Executive of NICE. We will of course fully work to any revisited set of NICE guidelines.”

    Source location

    2019-0202-Response-by-Shaw-Healthcare
    Page 1 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing NICE head-injury guidance already applies to injuries caused by both direct and indirect trauma.

    Verbatim wording from the response

    “We have considered the circumstances surrounding Mr Francis’ death and the concerns raised in your report and in particular the concerns that existing NICE guidance on head injury may not be appropriate for instances where a person experiences a non-direct head trauma.”

    Source location

    2019-0202-Response-by-NICE
    Page 1 · response
    Published 23 August 2019

    Open published response

  4. South Wales Central

    AI-generated summary

    Marion Hilda Prance · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marion Hilda Prance, aged 82, suffered a head injury after an unwitnessed fall at her care home and was given her usual morning dose of Rivaroxaban on the advice of paramedics. She was later diagnosed with a subdural haematoma, developed a catastrophic brain bleed and died the next day. The principal concerns were paramedic awareness and training regarding Rivaroxaban and the need for caution after head injuries caused by falls.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of paramedics to recognise that the extent of a head injury after a fall may not be immediately obvious and to apply extra caution

    Wider context from the report

    “(4) The awareness by paramedics that in patients with head injuries following a fall, the true extent of the head injury will not be immediately obvious, and extra caution is required. ”

    Source location

    Marion Hilda Prance · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Avon

    AI-generated summary

    Alexander Frederick Richard GREEN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alexander Green died at Southmead Hospital on 3 October 2017 after falling while out socialising and subsequently being found in the road. He was initially treated as intoxicated, and his head injury was not diagnosed until he suffered a respiratory collapse; the report identifies concerns about ineffective handover and communication, failure to apply head-injury guidance, and assumptions that intoxication explained his condition.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to apply the NICE head injury guideline before attributing depressed consciousness to intoxication

    Wider context from the report

    “2. The NICE guideline for head injury was not considered appropriate for use in this case when it is clearly designed for exactly this case – you ascribe depressed conscious levels to intoxication only after a significant brain injury has been excluded. ”

    Source location

    Alexander Frederick Richard GREEN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a tool guiding staff to exclude brain injury safely in intoxicated patients, including examination findings and a step-by-step head examination.

    Verbatim wording from the response

    “We are developing a tool that will assist and guide staff in safely excluding a brain injury in those patients who are believed to be intoxicated, that will strike the right balance between CT scanning those patients who need a scan and avoiding scanning those patients where a CT scan is only likely to cause potentially avoidable harm through exposure to radiation. It is envisaged that this tool will set out specific findings on an examination that might indicate a brain injury as opposed to intoxication, including a detailed step by step guide on how to carry out a thorough physical examination of a patient’s head.”

    Source location

    2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
    Page 2 · response
    Published 9 June 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish a pathway for senior review and further investigation when intoxicated patients do not recover within the expected timeframe after significant head injury is excluded.

    Verbatim wording from the response

    “For those patients in whom a significant head injury has been excluded and are diagnosed as being intoxicated, the Trust has developed a pathway to ensure that patients who fail to recover within the anticipated timeframe are reviewed by a senior doctor. This is to consider the possibility of an alternative diagnosis such as injury or illness not detected on initial assessment and to allow appropriate further investigations to be completed.”

    Source location

    2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
    Page 2 · response
    Published 9 June 2019

    Open published response

  6. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    John Robert Maltby Worthington · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Robert Maltby Worthington fell down stairs in late March or early April 2017 and was treated for a head injury, with back and neck pain noted. He was later found to have spinal and rib fractures and pneumonia, and died in hospital on 29 June 2017 from bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture. The concerns included not undertaking further imaging after the initial fall and not recording a full set of observations or conducting further investigations when he later saw his GP with persistent back pain.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to undertake further imaging in borderline presentations of significant head injury

    Wider context from the report

    “(1) The deceased attended A&E on the 4th April 2017.He had a very significant head injury 10 cm long requiring 15 stitches and exposing the skull. He had fallen downstairs. He gave a history of a fall from 4 steps. He complained of back and neck pain. Examination of the spine did not reveal any tenderness and other observations were within normal parameters. Further investigations were considered unnecessary and the NICE guidelines were considered. . The deceased’s presenting complaint appeared to fall within a grey area/borderline decision warranting further investigation by way of x-ray/scan. A decision was made not to do this. He later died from injuries sustained in that fall. It is understood that nationally work may be underway to reduce the threshold in such borderline cases. It may be of benefit to future patients for this matter to be further considered. ”

    Source location

    John Robert Maltby Worthington · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No further investigations were considered necessary because there were no clinical signs indicating a need at the time.

    Verbatim wording from the response

    “████████ felt that she provided a high standard of care to Dr Worthington at this consultation; having insisted that he attended the Practice for a face to face consultation and the carrying out a detailed assessment. ████████ clinical opinion at the time was that there were no untoward signs of head injury and there were no clinical signs at the time to suggest that any further investigations were needed. ████████ had listened to Dr Worthington’s chest and concluded that the lungs were clear.”

    Source location

    2018-0204-Response-by-MDDUS
    Page 2 · response
    Published 14 August 2018

    Open published response

  7. Manchester South

    AI-generated summary

    Edwin Hooper · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Edwin Hooper was admitted with multiple serious medical conditions, including decompensated heart failure, kidney disease, sepsis and peripheral vascular disease. After a fall while receiving anticoagulant treatment, he sustained a traumatic intracranial bleed and progressively deteriorated before receiving palliative care and dying on 15 November 2016. The principal concern was whether patients with head injuries who are taking anticoagulants undergo CT scanning in accordance with NICE guidelines, particularly when there are on-site CT scanner service issues.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure guideline-compliant CT scanning for patients with head injuries, especially those taking anti-coagulant medication, during on-site CT scanner service issues

    Wider context from the report

    “Please can you confirm what measures have been put in place to ensure patients with head injuries, especially those taking anti-coagulant medication, undergo CT scanning in accordance with NICE guidelines, particularly where there are service issues with CT scanners on site. ”

    Source location

    Edwin Hooper · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a CT scanner downtime escalation and dissemination process, supported by senior managers on call, out-of-hours protocol reminders, and posters in relevant clinical areas.

    Verbatim wording from the response

    “In summary the measures put in place are a robust escalation and dissemination plan for any occurrences of CT scanner downtime. This is backed up with senior managers on call and the out of hours team being sent and reminded on the CT scanner downtime protocol (embedded in the action plan). A poster has also been designed and displayed in all relevant clinical areas, which describes the process clearly.”

    Source location

    2018-0016-Response-by-Manchester-University-NHS-Trust
    Page 1 · response
    Published 8 March 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide training on NICE guidelines for hospital-acquired head injuries and require all new starters to complete it during Trust induction.

    Verbatim wording from the response

    “Training on NICE guidelines for the management of hospital acquired head injuries has been undertaken, and is sustained with all new starters having to complete this on induction to the Trust.”

    Source location

    2018-0016-Response-by-Manchester-University-NHS-Trust
    Page 1 · response
    Published 8 March 2018

    Open published response

  8. Milton Keynes

    AI-generated summary

    Peter (Peirce) Cotter · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter (Peirce) Cotter suffered an unwitnessed fall at home on 27 January 2017, sustaining a head injury and fractured hip, and later underwent hip surgery. The principal concern was that clinical decision support software did not appear to recognise the head injury despite his use of anticoagulant drugs.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of clinical decision support software to register head injuries

    Wider context from the report

    “During the course of the evidence it became apparent that Mrs Cotter had telephoned emergency services on 27th January 2017 and reported that her husband had had a fall, hit his head and hurt his hip. My concern is that the clinical decision support software system did not appear to register that Mr Carter had suffered a head injury. He was receiving anticoagulant drugs and even a minor head injury could have had catastrophic results if the head injury was not recognised and treated. I believe that there should be a review of the triage system to ensure that all head injuries are recognised and treated as emergencies. ”

    Source location

    Peter (Peirce) Cotter · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing head-injury questioning and NICE-consistent triage are considered sufficient to identify relevant risks and provide the appropriate emergency response.

    Verbatim wording from the response

    “Having reviewed the case and the Coroner’s concerns, I am in a position to reassure HM Coroner that NHS Pathways identifies and assesses head injuries through a detailed series of questions, and specifically identifies if callers are on anti-coagulant treatment. In this particular case we triaged the call via our head injury flow as an emergency and this resulted in an emergency department disposition via ambulance transport within 1 hour.”

    Source location

    2017-0388-Response-by-NHS-Digital
    Page 2 · response
    Published 9 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Trust cannot change NHS Pathways because it is designed and managed by NHS Digital.

    Verbatim wording from the response

    “To confirm the advice that you were given at the inquest hearing by ████████ our Legal Services Manager, NHS Pathways is a national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves.”

    Source location

    2017-0388-Response-by-South-Central-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 9 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for reviewing and changing NHS Pathways should be directed to NHS Digital.

    Verbatim wording from the response

    “To confirm the advice that you were given at the inquest hearing by ████████ our Legal Services Manager, NHS Pathways is a national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves.”

    Source location

    2017-0388-Response-by-South-Central-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 9 February 2018

    Open published response

  9. Black Country

    AI-generated summary

    Mrs Beryl Farmer · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Farmer was admitted to hospital with severe hypocalcaemia and postural hypotension, fell from her bed and sustained facial and head injuries, and was discharged without a documented falls risk assessment. She was readmitted after developing headaches, was diagnosed with a subdural haemorrhage, later developed seizures, and died; concerns included inadequate falls-risk assessment, moving her to an unmonitored bay, limited neurological observations, and no CT head scan after the fall.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to perform CT head scans after significant facial and head bruising

    Wider context from the report

    “4. In addition no CT Head scan was performed despite evidence of significant bruising to her face and head. ”

    Source location

    Mrs Beryl Farmer · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Recheck head-injury and inpatient-falls policies against NICE and NPSA standards.

    Verbatim wording from the response

    “We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff”

    Source location

    2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Install the new electronic patient record to provide decision support and alerts reinforcing inpatient-falls and head-injury standards.

    Verbatim wording from the response

    “We are going to amend our inpatient falls policy. This will help us to ensure that post incident monitoring is undertaken. It will also more clearly link our standards in ED and on the wards. It is unacceptable that in this situation the requested monitoring was discontinued. Our use of Vital Pac and the upcoming installation of our new electronic patient record by Christmas 2017 will provide decision support and alerts to reinforce our standards. These changes will be complete by the end of March 2017.”

    Source location

    2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing head-injury and inpatient-falls policies meet NICE and NPSA standards and remain suitable for staff use.

    Verbatim wording from the response

    “We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff”

    Source location

    2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    Open published response

  10. Milton Keynes

    AI-generated summary

    Frederick Squires · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Frederick Squires was involved in a low-impact road traffic collision, sustained a head injury, and was discharged home after his warfarin and other medications were stopped. He was later found unwell, diagnosed with an acute ischaemic stroke, and died on 30 December 2014. The principal concern was the lack of guidance for clinicians on when warfarin should be recommenced after a head injury.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of guidance on when to recommence Warfarin after head injury

    Wider context from the report

    “(1) That there is no guidance available to clinicians as to when Warfarin should be recommenced for a patient who has suffered a head injury. If clear guidance is not available it will lead to confusion amongst clinicians and the patient with the result that it is commenced too soon and the patient develops a bleed or too late and the patient suffers a stroke. ”

    Source location

    Frederick Squires · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider extending the head-injury guideline’s scope to examine evidence and develop recommendations on restarting warfarin during the 2017 update.

    Verbatim wording from the response

    “We have a guideline on the assessment and early management of head injury (accessible from our website: www.nice.org.uk/cg176), which includes recommendations regarding discharging patients. However, we believe that to examine the available evidence and make specific recommendations on when to restart Warfarin would require the guideline’s scope to be extended. We will consider the case for doing so, when we consider the guideline for updating in 2017.”

    Source location

    Response from National Institute for Health and Care Excellence
    Page 1 · response
    Published 31 October 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Specific recommendations on restarting Warfarin after head injury cannot be made without extending the guideline’s scope.

    Verbatim wording from the response

    “We have a guideline on the assessment and early management of head injury (accessible from our website: www.nice.org.uk/cg176), which includes recommendations regarding discharging patients. However, we believe that to examine the available evidence and make specific recommendations on when to restart Warfarin would require the guideline’s scope to be extended. We will consider the case for doing so, when we consider the guideline for updating in 2017.”

    Source location

    Response from National Institute for Health and Care Excellence
    Page 1 · response
    Published 31 October 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026