Ruth Diane Eggleton · Prevention of Future Deaths report

On 10 May 2023, I commenced an investigation into the death of Ruth Diane Eggleton.

The investigation concluded at the end of the inquest on 2 July 2024.

The conclusion of the inquest was a narrative conclusion:

Ruth Diane Eggleton fell whilst gardening, sustaining a head injury. Rivaroxaban was not withheld or reversed, and Mrs Eggleton was discharged from hospital on 2 April 2023, both of which more than minimally, negligibly or trivially contributed to her death from traumatic subdural haemorrhage.

On 2 April 2023, Ruth Diane Eggleton fell in her garden, sustaining a brain injury. A CT head scan undertaken on 2 April 2023 revealed a small subdural haemorrhage. Mrs Eggleton was anticoagulated with Rivaroxaban which was neither reversed nor discontinued on 2 April 2023. Mrs Eggleton was discharged from hospital on 2 April 2023.

Had Mrs Eggleton remained in hospital for neurological observations in accordance with NICE guidelines, she would have more than likely survived as those observations would have revealed Mrs Eggleton’s deterioration early on which would have led to reversal and cessation of Rivaroxaban, and allowed for surgical evacuation of the haemorrhage before Diane was too neurologically compromised. The subdural haemorrhage continued to ooze, contributed to by ongoing anticoagulation with Rivaroxaban. The continuation of Rivaroxaban more than minimally contributed to Mrs Eggletons’ death.

1. There is a lack of evidence-based protocol for determining when to withhold and/or reverse DOAC, and when to prescribe alternative anticoagulant medication. I heard evidence from clinicians that the lack of such a protocol has led to divergence of practice amongst clinicians.

I am not reassured that necessary actions to address the serious issue identified are in place.