Colin Bailey · Prevention of Future Deaths report

On 11th April 2018 an investigation into the death of Colin Bailey was commenced and an inquest opened on 19th April 2018. The Inquest was concluded on 19th March 2019 and the conclusion was one of Narrative:
Mr Bailey died as a result of a recognised risk of the use of anti-coagulant medication in combination with his co-morbid condition.
The medical cause of death was
1a Extensive subarachnoid haemorrhage bilaterally with intraventricular extension of bleed.
1b Hypertension
II Ischaemic stroke, atrial fibrillation requiring anti-coagulation, type 2 diabetes.

Mr Bailey was admitted to Stepping Hill Hospital following a stroke on 9th March 2018. He was transferred to Tameside General Hospital on 14th march 2018 to continue his rehabilitation. On 10th April 2018 his condition suddenly deteriorated. A CT scan of the head showed an extensive subarachnoid haemorrhage bilaterally with intraventricular extension of the bleed which was linked to and probably exacerbated by the use of anticoagulant medication. His health worsened and a as result of the subarachnoid haemorrhage he died at Tameside General Hospital on 10th April 2018.

The inquest heard that Mr Bailey fell and hit his head whilst an in-patient at Stepping Hill hospital. No CT scan of the brain/head was undertaken despite Mr Bailey taking anti-coagulant medication because NICE guideline recommended a scan is undertaken if the patient has fallen, struck their head and is taking warfarin but that is not the guidance if the anticoagulant medication is one of the other types of anticoagulant medications used. The clinicians attending the Inquest indicated that a CT scan in this scenario should be undertaken whatever the type of anti-coagulant medication and that is the Trust's own policy going forwards. There was concern that this ought to be national guidance.