Michael James Robert ROLFE · Prevention of Future Deaths report

On 02 September 2019 I commenced an investigation into the death of Michael James Robert ROLFE aged 72. The investigation concluded at the end of the inquest on 07 September 2022. The conclusion of the inquest was that:

The deceased presented on 23rd August 2019 to A&E at the Pilgrim Hospital, Boston. A CT scan disclosed an intercranial bleed. He was not a candidate for surgery. Anti coagulants had already been stopped. He declined and died.

Referral from ████████ Integrated Assessment Centre, Pilgrim hospital ████████
Due to death within 24hrs of admission.
Mr Rolfe is a 72 yr old man admitted on 23/8/19 at 1627hrs with decreasing consciousness.
He had a headache one day prior to admission.
CT scan showed left cerebellar haemorrhage with intraventricular extension, compression of fourth ventricle and brainstem and obstructive hydrocephalus. ITU team initially intubated and ventilated him. However after discussion with DMC Neurosurgery, who were of the opinion that the position was not treatable. Discussion was had with family.
He was extubated on 24/8/19 at the same day and transferred to the Stroke ward for EOLC.
He passed away at 0930hrs on 24/8/19.
PMH: TYPE 2 Diabetes mellitus, hypertension, non alcoholic steato hepatitis, hepatic encephalopathy, monoclonal gammopathy of undetermined significance, recent deep vein thrombosis started on Rivaroxaban, recent rectal bleeding.
Spoke to ████████ who is of the opinion that the Rivaroxaban most likely played a part in the bleed/death. He will liaise with his consultant ████████ (F) as to who will complete the Coroner’s report.
Decision taken for Consultant ████████ to complete circumstances of death with CoD.

With reference to cause of death at 1b.
The deceased had liver impairment due to cirrhosis. He was prescribed the anticoagulant Rivaroxaban for presumed deep vein thrombosis. Within 48 hours he developed rectal bleeding. During his admission to hospital his INR was 1.8 indicating blood was thin. Renal function impaired with a GFR of 39 - baseline 46. Rivaroxaban is contradicted in liver impairment, low platelets and severe renal impairment .(Documented in the product literature and British National Formulary). Consequently, it is represented that the deceased should not have been prescribed Rivaroxaban due to the bleeding risk. Administration of Rivaroxaban to someone with impaired clotting and low platelets would exaggerate the anticoagulant effect and be responsible for the rectal bleed and cerebral haemorrhage that resulted. If accepted the potential inappropriate administration may have led to the cause of death and this has important safety implications that are in the public interest. An action plan to prevent future deaths may be needed.