Ghulam Mohammad
14 Nov 2022 · Coroner Graeme Irvine · East London
The coroner's concerns
1. fall resulting in fatal injury
“A patient with a high risk of falls sustained a fatal injury in an avoidable fall in hospital”
2. delayed CT head
“Following that fall , an urgently requested CT head was delayed for four days”
3. administration of enoxaparin
“Before the requested CT head was undertaken, a doctor prescribed blood thinning medication - enoxaparin to Mr [name redacted]. Enoxaparin can exacerbate an intra-cranial bleed”
4. inadequate record keeping
“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. omission of enoxaparin use in reports
“Neither the Trust's initial SI investigation nor the consultant statement to the inquest mentioned the use of enoxaparin or the lack of clinical records justifying its use”