Thelma Doris Clarkson · Prevention of Future Deaths report

On 25th February 2015 I commenced an investigation into the death of Thelma Doris Clarkson. The investigation concluded at the end of the inquest on 19th November 2015. The conclusion of the inquest was:
Mrs Clarkson's medical cause of death was Acute Subdural Haematoma and I concluded that her death was due to an Accident. I enclose a copy of my Record of Inquest.

On 10th February 2015 Mrs Clarkson fell in her home. She sustained a number of injuries, including head injuries. She was taken to Gosport War Memorial Hospital where her injuries were treated and she was discharged home that afternoon. Following her return home, her condition deteriorated and she was taken by ambulance that evening to Southampton General Hospital where examination determined she had sustained an inoperable head injury from her earlier fall. She died at Southampton General Hospital on 11th February 2015.

Prior to her fall, Mrs Clarkson has for some time been prescribed and was taking the drug Clopidogrel for long-standing heart disease. The British National Formulary warns that patients taking Clopidogrel are at risk of increased bleeding from trauma. However, I was told in evidence at the Inquest that under the NICE Head Injury Pathway which was in use at the time at Gosport War Memorial Hospital, had Mrs Clarkson been taking Warfarin she would have been sent to a larger hospital to have a CT scan of her head but the Pathway did not include Clopidogrel as a similar trigger for a CT scan - notwithstanding the risk of increased bleeding from head trauma. I was also told that, had Mrs Clarkson been sent from Gosport War Memorial Hospital for a CT scan, there is a strong possibility it would have revealed the extent of her head injury and her treatment - and its potential outcome - may have been different. I am therefore concerned that the NICE should consider whether its Head Injury Pathway should be amended to include taking Clopidogrel as a trigger for a CT scan in the same way as Warfarin presently does.