Ghulam Mohammad · Prevention of Future Deaths report

On 19th October 2021 I commenced an investigation into the death of Ghulam Mohammad age 89 years. The investigation concluded at the end of the inquest on 19th April 2022 and 6th October 2022. I made a determination of a narrative conclusion as:

Mr Ghulam Mohammad was admitted to hospital on 9th October 2021. Whilst an inpatient he suffered a fall on 11th October 2021, he died as a consequence of injuries sustained in that fall on 18th October 2022.
Mr Mohammed’s medical cause of death was determined as;

1a Subdural Haematoma
1b Community Acquired Pneumonia
1c
II Chronic Kidney Disease, Type 2 Diabetes Mellitus, Hypertension

Ghulam Muhammed an 89-year-old man admitted to hospital 9/10/21 by ambulance following an unwitnessed fall. On admission his blood results showed; coagulopathy and acute kidney injury.

Imaging showed no intra-cranial bleed but was suggestive of pneumonia and faecal impaction. He was treated with IV fluids anti-biotics. Mr Mohammed was prescribed Vitamin K after discussion with Haematology.

On 11/10/21 Mr Mohammed sustained a fall in the bathroom causing a head injury, he became more confused. Following a medical review an urgent CT head was requested.

A CT head was not undertaken until 15/10/2021, a four-day delay.

Prior to undergoing the CT head – Mr Mohammed was prescribed low molecular weight heparin, a prophylactic against the risk of venous thromboembolism which impedes clotting function.

The CT head identified a large right-sided subdural haematoma with a midline shift. Following neurological advice conservative management was given, the patient’s condition deteriorated and he sadly passed away on the 18/10/2021.

1. A patient with a high risk of falls sustained a fatal injury in an avoidable fall in hospital.
2. Following that fall, an urgently requested CT head was delayed for four days.
3. Before the requested CT head was undertaken, a doctor prescribed blood thinning medication – enoxaparin to Mr Mohammed. Enoxaparin can exacerbate an intra-cranial bleed. The medication was administered on 13 & 14th October 2021. Both the prescription and the administrations of enoxaparin were made without knowing the extent of any intra-cranial damage caused by the fall on 11/10/21.
4. Inadequate record keeping meant that there was no contemporary account of the factors taken into consideration by the doctor or her supervising consultant in prescribing enoxaparin.
5. Neither the Trust’s initial investigation nor the consultant statement to the inquest mentioned the use of enoxaparin or the lack of clinical records justifying its use.