Background

The patient was an 81-year-old male long-term care resident with late-stage dementia. The patient allegedly sustained head trauma from a feeding tube pump that fell when he became agitated and restless. The patient’s cause of death was massive subdural hematoma.

Services Provided

Rimkus experts were tasked with answering the following questions:

• Were the injuries consistent with reports of the accident?
• Were there alternative causes of his brain bleed, other than trauma?

Our Legal Nurse Consultant (LNC) carefully reviewed the medical records, looking for facts to answer the client’s questions. The autopsy showed no external signs of trauma. The records from the feeding tube insertion were missing. A review of records from prior hospitalizations showed the patient had a history of chronic subdural hematomas. These records included a handwritten note by a hematologist stating “No Aspirin or anticoagulation” due to the patient’s high risk of extending subdural hematoma.

We advised the client to obtain records from the tube feeding admission. When received, our LNC discovered that the patient was given five doses of subcutaneous heparin during his stay, just one week prior to his death from subdural hematoma.