Kenneth Edwards · Prevention of Future Deaths report

On the 16th April 2025, an inquest was opened concerning the death of Kenneth Edwards, aged 85 years at the time of death. The inquest concluded on the 1st August 2025.

The medical cause of death was: 1a) Acute Traumatic Subdural and Subarachnoid Haemorrhage

The conclusion of the inquest was as follows [narrative]: Kenneth Edwards died as a consequence of bleeding to the brain caused by two falls, which was contributed to by blood-thinning medication administered to him whilst in hospital.

On the 22nd March 2025, Kenneth Edwards fell whilst walking in the street. He was taken to Stepping Hill Hospital where at 18:51 hours he underwent a CT scan. The CT scan was reported as showing no intracranial haemorrhage. On the morning of the 23rd March 2025, Kenneth Edwards fell again whilst at the hospital. At 11:30 hours he underwent a second CT scan of his head to assess whether this second fall had caused bleeding. At 12:23 hours, whilst awaiting the results of that scan, he was administered medication including the blood thinning medications clopidogrel and enoxaparin. The administration of these medications whilst awaiting the results of a CT scan to rule out brain bleeding is not best practice; they are contra-indicated in such circumstances. The scan results were read at 12:28 hours: the scan indicated a subdural haemorrhage and a subarachnoid haemorrhage. Kenneth Edwards died on the 23rd March 2025.

The rapid review conducted after the death of Kenneth Edwards included amongst its findings a review of the first CT scan. On that review it was found that there was a thin subdural haematoma that had not been reported.

1. A subdural haematoma was not identified in the report on the first CT scan [18:51 hours on 22nd March 2025, reported at 19:30 hours]. The inquest heard that since this scan took place out of hours (i.e. between 17:00 and 09:00) hours it was dealt with by an out of hours service provided by a company called Medica. The rapid review which identified the haematoma after Kenneth Edwards’s death was conducted by one of the hospital’s own radiologists. Had the haematoma properly been identified at the time the first scan was reported, appropriate steps could have been taken to deal with it at a relatively early stage. Furthermore, this would have identified circumstances at an early stage of Kenneth Edwards’s treatment that militated against the administering of blood-thinning medication.

2. Evidence was given that this was not the first time that detail had been missed on a scan reported upon by Medica.

3. The administration of blood-thinning medication whilst awaiting the results of the second CT scan of the head to identify bleeding should not have happened. Whilst the treating clinician/s could not have known about the bleed that had not been identified on the first scan, they should have known that such medications were contra-indicated where the results of the second scan to identify brain bleeding were awaited.