Jeffrey Marshall

Ms Anna Loxton, HM Assistant Coroner for Surrey

The inquest into the death of Jeffrey MARSHALL was opened on 4 th January 2024.  Evidence was heard and the inquest was concluded on 13 th June 2024. Mr Marshall died at St Peter’s Hospital in Chertsey on 13 th December 2023, aged 72 years. I found the medical cause of death to be: 1a. Ischaemic Stroke 1b. Thrombosis of Basilar Artery 1c. Atherosclerosis of Basilar Artery

1. Previous Subdural Haematoma; Hypertension; Diabetes Mellitus;

Atrial Fibrillation; Cessation of Anticoagulation Therapy I found that whilst the cause of death was natural, it was contributed to by the withholding of anticoagulation therapy over the previous 47 days prior to death. Mr Marshall had sustained a subdural haematoma in a fall on 21 st October 2023, following which his anticoagulation therapy was withheld pending further CT scan to check that this had resolved before recommencing anticoagulation. Whilst a further CT scan took place on 8 th November 2023, this was not reported until 3 rd December 2023, and Mr Marshall’s GP was informed by the  Hospital  that  his  anticoagulation  should  be  recommenced  on  6 th December  2023.  Mr  Marshall  suffered  an  ischaemic  stroke  on  7 th December 2023 as a result of thrombosis of the basilar artery, of which he was at increased risk due to the withholding of anticoagulation therapy. He deteriorated until his death. I heard evidence from a Stroke Consultant at Ashford and St Peter’s Hospitals  NHS  Foundation  Trust  that  the  half-life  of  Direct  Oral anticoagulants is short and therefore the benefit of its risk reduction for thrombus is lost within a short period of time, placing the patient at high risk of stroke. She detailed that whilst it is standard protocol to withhold anticoagulation following a head injury, there is no national guidance (e.g. from the National Institute for Health and Care Excellence) to assist in determining when anticoagulation should be recommenced. There is also   no   guidance   for   clinicians   to   discuss   the   withholding   of anticoagulation  and  the  risks/benefits  of  this  with  patients,  to  enable them  to  make   an  informed  decision   as  to  when  to  recommence anticoagulation in this scenario. I recorded a narrative conclusion of Natural Causes contributed to by withholding   of   anticoagulation   over   47   days   following   subdural haematoma.

Mr Marshall died from an ischaemic stroke at St Peter’s Hospital in Chertsey on 13 th December 2023. He had suffered a fall whilst exiting a car on 21 st October 2023, in which he sustained  an  acute  subdural  haematoma.  His  anticoagulation  therapy  of Edoxaban,  prescribed  for  atrial  fibrillation  and  permanent  pacemaker,  was withheld in accordance with NICE guidance. Neurosurgeons at St George’s Hospital in Tooting gave advice and reiterated the need to withhold anticoagulation and to monitor the bleed via further CT scan the following day, and again two weeks thereafter. The last scan on 8 th November 2023 revealed that the haematoma had resolved, but this was requested on a routine basis with a reporting time of 28 days. It was therefore reported on Sunday 3 rd December, and Mr Marshall’s GP was advised that anticoagulation could be restarted on 6 th December 2023. Mr Marshall suffered a sudden loss of consciousness at home on the evening of 7 th December 2023 and was admitted to St Peter’s Hospital, where he was found to have suffered a Basilar Artery Thrombosis and Basilar Territory Infarction. His anticoagulation had been withheld for 47 days on a background of atrial fibrillation   and   permanent   pacemaker,   increasing   his   risk   of   thrombus development. Mr Marshall’s stroke was not survivable and he died on 13 th December 2023.

The MATTERS OF CONCERN are: Mr   Marshall   was   prescribed   anticoagulation   (Edoxaban)   to mitigate his increased risk of developing thrombus due to atrial fibrillation and a permanent pacemaker; Anticoagulation was withheld following a traumatic head injury, in accordance with NICE guidance; There is no national guidance to assist clinicians in determining when anticoagulation should be recommenced in this scenario, nor any recommendation for clinicians to discuss the risks and benefits of withholding anticoagulation with patients to enable them to make   an   informed   decision   as   to   when to recommence anticoagulation. Consideration should be given to whether any steps can be taken to address the above concerns.

In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action.