PFD report

Lucy KILVERT · Prevention of Future Deaths report

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Issued 15 Oct 2013•Black Country

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
0

Of 3 recipients

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

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Concerns and recipient responses

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Concerns raised2

  1. NICE Guidelines insufficiently emphasising blood-thinning medication in elderly people who have a fall when determining the need for a head CT
  2. Delays in performing a CT scan of the head after hospital presentation
    Part of recurring concern: Failure to provide timely access to clinically indicated CT scanningPart of recurring concern: Unreliable timeliness of radiology imaging and reporting
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

NICE Guidelines insufficiently emphasising blood-thinning medication in elderly people who have a fall when determining the need for a head CT

Wider context from the report

“namely that Mrs Kilvert was not initially at the hospital given a CT scan of the head. It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was :- 1a) Intracranial bleed, II Chronic Kidney Failure Hypertension Heart Valve Replacement. As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. I was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect a bleed, although the consultant said that his judgment may have been different. The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had a fall when considering whether a CT scan of the head was necessary, albeit that eventually the matter was a question of clinical judgment. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in performing a CT scan of the head after hospital presentation

Wider context from the report

“namely that Mrs Kilvert was not initially at the hospital given a CT scan of the head. It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was :- 1a) Intracranial bleed, II Chronic Kidney Failure Hypertension Heart Valve Replacement. As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. I was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect a bleed, although the consultant said that his judgment may have been different. The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had a fall when considering whether a CT scan of the head was necessary, albeit that eventually the matter was a question of clinical judgment. ”

Is this part of a recurring concern?

Yes — Failure to provide timely access to clinically indicated CT scanning; Unreliable timeliness of radiology imaging and reporting.

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026