Phyllis Eleanor Barlow · Prevention of Future Deaths report

On 12th November 2014 I commenced an investigation into the death of Phyllis Eleanor Barlow aged 83. The investigation concluded at the end of the inquest on 29th January 2015. The medical cause of death was: 1A Subdural haemorrhage (operated) and 2. Fracture left neck of femur (operated), Deep vein thrombosis (fully anticoagulated), and the conclusion of the inquest was a narrative conclusion as follows: “Phyllis Eleanor Barlow died on the 8th November 2014 from a subdural haemorrhage sustained after a fall at home on the 30th September 2014. It is likely that the fall and her death were contributed to by significant natural disease and the appropriate medication given for it.”

Phyllis Barlow was on a variety of medication for her existing co-morbidities, including warfarin to treat a deep vein thrombosis. On 29th September 2014 she fell in the GP surgery car park striking her head. She was treated for a minor abrasion and her observations were all normal. She went home after this without any difficulty. On 30th September 2014 she fell and struck her head at home, causing a subdural haemorrhage and fracturing her hip. She was taken to hospital where she was treated appropriately but died on 8th November 2014.

(1) At the time of her fall in the GP car park on 29th September 2014 NICE guidelines (on head injuries) were in place to the effect that anyone suffering a head injury who was on warfarin should be admitted to hospital forthwith and undergo a CT scan. ████████ who appeared at the inquest on behalf of the GP practice testified that these NICE guidelines were not known or appreciated by her GP practice at the time even though they were in force. Mrs Barlow was not admitted to hospital as she should have been on 29th September 2014. ████████ subsequent enquiries have revealed that there is widespread ignorance of these NICE guidelines among GP colleagues, although they are appreciated by the ambulance service, and A&E departments.

The Coroner is concerned that steps should be taken to make GP surgeries in Wales aware of the importance of these NICE guidelines, and that anyone who suffers a head injury while being treated with Warfarin should be admitted to hospital forthwith and a CT scan undertaken on them..