Georgia Polydorou · Prevention of Future Deaths report

On 19 September 2017, I commenced an investigation into the death of Georgia Polydorou who was born on 12 July 1937. The investigation concluded at the end of the inquest, which was conducted by me on 29 January and 6 March 2018.

The conclusion of the inquest was a narrative conclusion. I recorded a medical cause of death of:
1a ventilator associated bronchopneumonia
1b subdural haematoma (operated 11.7.2017)
1c fall
2 mitral valve regurgitation, atrial fibrillation, hypertension, congestive cardiac failure and Beta trait thalassaemia.

Mrs Polydorou was an in-patient at Homerton University Hospital due to an exacerbation of congestive cardiac failure. She was recognised to be at increased risk of falls. She was prescribed aspirin, clopidogrel and enoxaparin during her admission. In the early hours of 10 July 2017, Mrs Polydorou fell whilst going to the toilet. She was reviewed by the on call doctor and subject to neurological review every 15 minutes for the first hour and hourly observations thereafter. Her Glasgow Coma Score following the fall was 15/15. It was decided that a CT scan would be undertaken if Mrs Polydorou showed signs of deterioration such as headache, bleeding, dizziness or vomiting. Later in the day, she was reviewed by a junior doctor. As she had had 10 sets of normal neurological observations, a decision was made to revert to standard nursing observations. Mrs Polydorou told family members that she had a headache but she did not mention this to hospital staff. At 6.40 am on 11 July, a nurse went to take Mrs Polydorou’s observations and found her unresponsive but breathing. An urgent CT scan showed a large right sided acute subdural haematoma. Mrs Polydorou was transferred to the Royal London Hospital where she underwent an immediate right mini craniotomy and evacuation of the acute subdural haematoma. Her recovery was extremely slow. Mrs Polydorou remained on a ventilator in the Intensive Care Unit for several weeks. During which time, she had multiple episodes of ventilator-associated pneumonia, which were treated with antibiotics. Mrs Polydorou died at the Royal London Hospital on 18 September 2017. The Homerton University Hospital has revised its procedures regarding anti-coagulation and falls as a result of Mrs Polydorou’s death.

(1) Mrs Polydorou did not receive a CT scan within 8 hours of her fall because she had a Glasgow Coma Scale of 15/15, she did not have any abnormal neurological observations and was not taking Warfarin. Mrs Polydorou was concurrently taking aspirin, clopidogrel and enoxaparin during her hospital admission. All of which have the effect of thinning the blood.
(2) Evidence from a consultant neurosurgeon established that there can be a significant delay in elderly patients showing signs of head injury following a fall, particularly where they are taking blood thinning medications.
(3) Mrs Polydorou’s first language was Greek. Witnesses described her ability to converse in English as “basic”. Whilst in A&E, her son acted as an interpreter in order to obtain a reliable history. Following the fall, it was decided that Mrs Polydorou would have a CT scan if she showed signs of deterioration such as headache, bleeding, dizziness or vomiting. Mrs Polydorou’s son, ████████ was told that his mother had fallen but was not told of the significance that may indicate that her condition was deteriorating. During a visit on 10 July, Mrs Polydorou told her son that she had a headache but he did not realise the potential significance of this. Mrs Polydorou did not report her headache to medical staff.