“S are as follows: When found on the floor the deceased stated that he had a head injury”
Dated 15 Dec 2020, from the coroner for Hampshire, Portsmouth and Southampton. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 9 Feb 2021.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated15 Dec 2020
- Deadline9 Feb 2021
- Published on judiciary.uk7 Jan 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| University Hospital Southampton NHS Foundation Trust | Response publishedPublished on judiciary.uk in January 2021. |
The coroner’s concerns
S are as follows: When found on the floor the deceased stated that he had a head injury. The Trust has a policy for the assessment and early management of head injuries. The policy was, on the evidence, drafted in 2016. The Trust policy is said to reflect the National Institute for Health and Care Excellence guidance on the assessment and early management of head injuries. The deceased was receiving the anticoagulant enoxaparine whilst in hospital. The present Trust policy states that a computerised tomography scan of the head should be undertaken within 8 hours of the injury if a patient is receiving anticoagulant treatment. The evidence suggested that enoxaparine is a “low dose anticoagulant” which did not place the deceased within the Trust policy where a computerised tomography scan should be provided within 8 hours of a head injury. The Trust were not aware of the September 2019 variation in National Institute for Health and Care Excellence guidance which now advises that patients who are on any anticoagulant should have a computerised tomography scan within 8 hours of a head injury. The Trust’s policy does not presently reflect the National Institute for Health and Care Excellence revised guidance, in place since September 2019. It was accepted in evidence that the deceased would have had a computerised tomography scan within 8 hours of a head injury if the revised National Institute for Health and Care Excellence guidance had been applied and reflected in the Trust policy. The deceased’s computerised tomography scan was undertaken 30 hours after the deceased had suffered a head injury. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 09 February 2021. I, the coroner, may extend the period.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2020-0285
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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