Doctors may not have appreciated the urgency of the need to combat the effect of blood thinners on an elderly man who died from a fall in Wexham Park Hospital, a report has found.
John Tarrant died in hospital aged 84 after falling.
Though doctors were aware he was on blood thinners, the fall resulted in an ‘unsurvivable’ brain bleed.
When someone dies in a way that is potentially avoidable, a coroner may issue a prevention of future deaths report to try to make sure it does not happen again.
One such report, assembled by assistant coroner for Berkshire, Robert Simpson, was published on April 13 for Mr Tarrant.
A year ago, on April 26, 2025, Mr Tarrant was taken to Wexham Park Hospital in an ambulance.
He was suffering from a chest infection and delirium, and his legs were unable to bear his weight.
Testing showed he also had a very high bleeding risk due to his prescription blood-thinners.
He had a history of heart problems, including an irregular heartbeat, narrowed heart arteries, and an artificial heart valve.
Mr Tarrant was treated with antibiotics for his infection and to reduce his bleeding risk, his blood-thinner was stopped.
While in hospital, his delirium reduced and he became alert. He was also able to put weight on his legs again, though his risk of bleeding remained elevated.
Despite this improvement in Mr Tarrant’s condition, , he suffered a fall and died three days after his admission to Wexham Park, on April 29.
At about 4.30pm, he was in his bathroom, washing his hands in the sink. He told hospital staff he was OK. A healthcare assistant waited outside the door to escort him back to bed.
But there was a noise and when she looked again, Mr Tarrant was on the floor.
When doctors checked him, a scan showed he had a ‘very small’ bleed in the brain.
The neurosurgery department advised against surgery but suggested seeking advice from heart and blood specialists about using medication to reverse the effects of his blood thinners.
But no reversal agent was given to Mr Tarrant.
He suffered a decrease in consciousness and became unresponsive.
Another scan revealed an ‘unsurvivable’ brain bleed and he died about nine hours after his fall.
In his report, Mr Simpson said there were matters of concern, including that only two falls risk assessments were carried out after Mr Tarrant arrived at the hospital.
Hospital staff assessed how likely Mr Tarrant was to fall using a standard scale intended for this purpose, but they used the wrong information to calculate his score.
Some of the mistakes were notable; for example, in the risk assessment carried out hours after his fall, it stated that he had not fallen before.
Frimley NHS Foundation Trust, which runs Wexham Park, does ‘not have a way of assessing’ the accuracy of these risk assessments, the coroner’s report says.
The result was that the falls risk assessments said Mr Tarrant was at a low risk of falls ‘which was not correct.’
Further, Mr Simpson felt that doctors ‘did not appreciate the urgency of the situation’ after Mr Tarrant’s fall.
Though the hospital’s fall report form noted he was on blood thinners, it failed to remind the doctor to take that into account when deciding how to treat him afterwards.
This means that the urgency of giving him a reversal medication may have been ‘underappreciated’.
“In my opinion there is a risk that future deaths could occur unless action is taken,” Mr Simpson wrote.
Frimley NHS Foundation Trust, which runs Wexham Park Hospital, has a duty to respond to the prevention of future deaths report, detailing what action it plans to take and under what timescales, by May 25.
A spokesperson for the Trust said Frimley has already began acting on the report findings, including replacing its falls risk assessment with a ‘new, simpler approach’ reducing the potential for user error.
They added that they regularly check that staff are filling in falls risk assessments properly and that the right steps are being taken to reduce the risk of patients falling.
After a patient falls, there is a section in their electronic record that guides staff through what checks to carry out and what actions to take.
Frimley is also running an ongoing programme involving different teams to try to reduce the number of patients who fall in hospital and limit the harm caused by those falls.
“We extend our deepest sympathies to Mr Tarrant’s family and are very sorry for their loss,” said the spokesperson.
“The Trust will set out further detail in its formal response to the coroner within the required timeframe.”