Frederick Squires · Prevention of Future Deaths report

On 15/01/2015 I commenced an investigation into the death of Frederick Squires, 87. The investigation concluded at the end of the inquest on 13/10/2016. The conclusion of the inquest was a Narrative conclusion as attached.

On 4th December 2014 Mr Squires was involved in a road traffic collision where he was struck by the rear of a slowly reversing vehicle. The collision was low impact but on falling to the floor, Mr Squires struck his head. He was taken to Milton Keynes Hospital where a CT was performed and his warfarin and medications were stopped. He was admitted to ward 19 on 5th December 2014 and was discharged home on 6th December 2014 with instructions to see his GP as an outpatient to arrange another CT scan and he was not to start taking his medications until the results of the second CT scan were available. His second CT scan was booked for 29th December 2014.

Early on the morning of the 21st December 2014 the deceased was found on the toilet in the bathroom. An ambulance was called and the deceased was taken to the Luton and Dunstable hospital where a CT scan of his head showed he had an acute ischaemic stroke. He died on the 30th December 2014. ████████ has maintained that she was concerned at the withdrawal of all his medications and had expressed this on several occasions.

(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.