Doctors may not have\u00a0appreciated 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.<\/p>\n
John Tarrant died in hospital aged 84 after falling.<\/p>\n
Though doctors were aware he was on blood thinners, the fall resulted in an \u2018unsurvivable\u2019 brain bleed.<\/p>\n
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.<\/p>\n
One such report, assembled by assistant coroner for Berkshire, Robert Simpson, was published on April 13 for Mr Tarrant.<\/p>\n
A year ago, on April 26, 2025, Mr Tarrant was taken to Wexham Park Hospital in an ambulance.<\/p>\n
He was suffering from a chest infection and delirium, and his legs were unable to bear his weight.<\/p>\n
Testing showed he also had a very high bleeding risk due to his prescription blood-thinners.<\/p>\n
He had a history of heart problems, including an irregular heartbeat, narrowed heart arteries, and an artificial heart valve.<\/p>\n
Mr Tarrant was treated with antibiotics for his infection and to reduce his bleeding risk, his blood-thinner was stopped.<\/p>\n
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.<\/p>\n
Despite this improvement in Mr Tarrant\u2019s condition,\u00a0, he suffered a fall and died three days after his admission to Wexham Park, on April 29.<\/p>\n
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.<\/p>\n
But there was a noise and when she looked again, Mr Tarrant was on the floor.<\/p>\n
When doctors checked him, a\u00a0scan showed he had a \u2018very small\u2019 bleed in the brain.<\/p>\n
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.<\/p>\n
But no reversal agent was given to Mr Tarrant.<\/p>\n
He suffered a decrease in consciousness and became unresponsive.<\/p>\n
Another scan revealed an \u2018unsurvivable\u2019 brain bleed and he died about nine hours after his fall.<\/p>\n
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.<\/p>\n
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.<\/p>\n
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.<\/p>\n
Frimley NHS Foundation Trust, which runs Wexham Park, does \u2018not have a way of assessing\u2019 the accuracy of these risk assessments, the coroner\u2019s report says.<\/p>\n
The result was that the falls risk assessments said Mr Tarrant was at a low risk of falls \u2018which was not correct.\u2019<\/p>\n
Further, Mr Simpson felt that doctors \u2018did not appreciate the urgency of the situation\u2019 after Mr Tarrant\u2019s fall.<\/p>\n
Though the hospital\u2019s 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.<\/p>\n
This means that the urgency of giving him a reversal medication may have been \u2018underappreciated\u2019.<\/p>\n
\u201cIn my opinion there is a risk that future deaths could occur unless action is taken,\u201d Mr Simpson wrote.<\/p>\n
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.<\/p>\n
A spokesperson for the Trust said Frimley has already began acting on the report findings, including replacing\u00a0its\u00a0falls risk assessment with a \u2018new, simpler approach\u2019 reducing the potential for user error.<\/p>\n
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.<\/p>\n
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.<\/p>\n
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.<\/p>\n
\u201cWe extend our deepest sympathies to Mr Tarrant\u2019s family and are very sorry for their loss,\u201d said the spokesperson.<\/p>\n
\u201cThe Trust will set out further detail in its formal response to the coroner within the required timeframe.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"Doctors may not have\u00a0appreciated the urgency of the need to combat the effect of blood thinners on an…\n","protected":false},"author":2,"featured_media":555571,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[43],"tags":[102,2960,8934,56,54,55],"class_list":["post-555570","post","type-post","status-publish","format-standard","has-post-thumbnail","category-healthcare","tag-health","tag-healthcare","tag-premium","tag-uk","tag-united-kingdom","tag-unitedkingdom"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/posts\/555570","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/comments?post=555570"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/posts\/555570\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/media\/555571"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/media?parent=555570"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/categories?post=555570"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/uk\/wp-json\/wp\/v2\/tags?post=555570"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}