Leslie William Carswell · Prevention of Future Deaths report

On 10/12/2015 I commenced an investigation into the death of Leslie William Carswell. The investigation concluded at the end of the inquest 19th April 2016. The conclusion of the inquest was that the deceased died from a brain bleed following a fall. There was a delay in reviewing the CT scan and administering heparin more quickly which contributed to his death.

The deceased was admitted to D7 at City Hospital on 18/11/15 following a transcatheter aortic valve implantation at New Cross Hospital. He was transferred to ward D47 on 22/11/15 for rehabilitation. He was assessed to be at high risk of falls. He was seen regularly by physiotherapists and assessed to be improving. He had capacity and was informed to use his call bell when mobilising. At 19.25 on 29/11/15 the deceased was found face down on the floor having been to use the toilet. He was taken to Sandwell hospital emergency department, as per protocol, where a CT scan at 00.50 confirmed bilateral sub-acute on chronic subdural haematoma. A decision was made at 02.30 to give Beriplex to reverse the effects of warfarin however the deceased suffered a further serious bleed at 05.05 before this could be given. He died on the intensive care unit at 12.30 on 30/11/15.

(1) There were technical difficulties transmitting the CT scans taken at 00.50 to the Queen Elizabeth Hospital in Birmingham for review which is the protocol for these west midlands. This caused a delay in deciding a treatment plan. I heard evidence at the inquest that these concerns are ongoing and no resolution has been found. There is a concern that patients with urgent conditions could have lifesaving treatment delayed due to technical difficulties between the two trusts.