A patient at Ramsey Cottage Hospital died by accident, an inquest has ruled.
But coroner John Needham said it was important for medical staff to be reminded of protocols to be practised in relation to head injuries when patients were taking anti-coagulant medication.
The court heard 90-year-old Doris Mary Swallow was an in-patient at the hospital when she fell hitting her head. Witnesses said Mrs Swallow was unsteady on her feet and used a three-wheeled Zimmer frame-type walking aid.
She also suffered from dementia and was being treated in hospital until a nursing home space could be found for her.
A member of the hospital staff was taking her to use the toilet when she fell completely without warning, in the corridor near the toilet entrance.
An emergency call was made to the nearby doctors’ surgery and it was recommended she be put to bed but kept under observation at 15 minute intervals for the next two hours. However, despite taking Warfarin, she was not sent for a CT scan which would have detected bleeding in the brain. Over the next few hours Mrs Swallow’s condition deteriorated and she was transferred to Noble’s Hospital where she died from a subdural haemorrhage on September 2.
The court heard Mrs Swallow’s injury would have been fatal even if it had been detected earlier by means of a CT scan.
Recording his verdict, Mr Needham said he would make a recommendation to the Department of Health stressing the importance of following the policy on head injuries and the need for it to be known to all healthcare staff. He also recommended medical staff receive refresher training.
The policy was established in 2009 after June Sheath died from a head injury which was initially undetected.