From the Lord Prior of Brampton Department Parliamentary Under Secretary of State for Health (Lords) of Health 0 Ms Julie Robertson Richmond House Assistant Coroner for Manchester North 79 Whitehall London HM Coroner' s Office SWIA ZNS Phoenix Centre, LICPL Stephen Shaw MC Rochdale Tel: 020 7210 4850 OLIO ILR 13 OCT 2016 Lkbc Thank you for your report of 7 September 2016, following the inquest into the death of Dildar Shariff: [ was very sorry to hear of Mr Shariff s death in 2016 and wish to extend my sincere condolences to his family: In your letter you consider there to be a lack of awareness among clinicians that an increased risk of haemorrhage is likely to occur in people undergoing haemodialysis, or those with significant uremia due to renal failure. You have therefore asked NICE to consider amending its relevant guidance for clinicians. Iam aware of NICE'$ response and have noted its decision not to update its guidelines at the moment in relation to assessment and early management ofhead injury: Inote that NICE has logged your report and the information will be looked at when the guidance is next updated in 2017. Lam grateful to you for bringing the circumstances of Mr Shariff s death to my attention DAVID PRIOR '2006 OCt Way Mr May again

Dear Ms Robertson, I write in response to the Regulation 28 Report into the death of Mr Dildar Shariff. I was very sorry to learn of Mr Shariff’s death You explain in your report that you consider there to be a lack of awareness within the medical profession that people undergoing haemodialysis, or those with significant uremia due to renal failure, are at increased risk of a haemorrhage. Subsequently, you’ve asked for the significance of a head injury in such people to be incorporated into NICE guidelines. We have noted the circumstances around Mr Shariff’s death and the concerns you have raised, in relation to our existing guideline on the assessment and early management of head injury (accessible from our website: www.nice.org.uk/cg1 76). Where our head injury guideline refers to “any history of bleeding or clotting disorders” as a risk factor in the assessment of head injury, we do not list all the possible causes or scenarios, as it would be difficult to offer an exhaustive list. However, it is our view that it is widely known by clinicians that people with renal failure, including those with uremia or on haemodialysis, are at an increased risk of bleeding (especially where warfarin anticoagulation is used). Based on the circumstances you have described, we believe that at the second visit to the urgent care centre there was an opportunity for Mr Shariff to have had a CT scan (see recommendations in our head injury guideline that cover the criteria for performing a CT head scan in adults, specifically recommendations 1 .4.7 and 1 .4.8 which refer to risk factors of “more than I episode of vomiting” and “any history of bleeding or clotting disorders”, respectively). Alternatively, he could have been admitted for observation (see recommendation 1 .8, which sets out the criteria for

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admitting patients to hospital following a head injury, and includes “Continuing worrying signs (for example, persistent vomiting, severe headaches) of concern to the clinician” in the list). While we believe that our guideline does not need to be amended as a result of your report, your concerns have been logged with our guideline surveillance team, for their information when the guidance is next considered for update in 2017.