Selina Isabella Broadhurst · Prevention of Future Deaths report

On 21st February 2013 I commenced an investigation into the death of Selina Isabella Broadhurst dob 1st January 1927. The investigation concluded on the 12th February 2014 and the conclusion was one of Accidental Death. The medical cause of death was 1a Bronchopneumonia 1b Intra-cerebral Haemorrhage and 2 Vascular dementia and Type two diabetes mellitus.

On the 14th February 2013 she fell at the E.P.H. where she lived and suffered a blow to the head. She was admitted to hospital and, inter alia, she was not afforded a CT scan of her head until a second admission some hours later when she was shown to have a major bleed to the brain. This was despite the fact that she had an external injury to the front of her scalp.

The Emergency Department doctors indicated that they could not get a CT of the head because “the NICE Guidelines do not indicate as being appropriate where there are no obvious neurological signs”.
I have noted in this inquest and indeed in a number of inquests previously that the doctors are following these guidelines and in fact many severe brain injury cases are being missed or there is a delay in diagnosis. Is it not now time that this guideline was re-examined and the advice amended, especially when dealing with the very frail elderly patient?