On the 2rd August 2019, an inquest was opened into the death of Maureen Waterfall, who died on 26th July 2019 at Willow Wood Hospice at Mellor Rd, Ashton-under-Lyne OL6 6SL, at the age of 72 years. The investigation concluded with an inquest which heard on 18th December 2019 and which concluded with a Conclusion that Mrs Waterfall died from the consequences of a brain injury sustained during a fall which were complicated by the previous use of prescribed Edoxaban:

Mrs Waterfall had a successful heart operation at the Liverpool Heart and Chest Hospital in November 2018. As part of the post-operative treatment; an anticoagulant; Edoxaban, was prescribed. Mrs Waterfall fell at home on the morning of 12t July 2019 shortly before 9.OOam. She sustained an injury to the back of her head which bled and she went, accompanied by a friend, to the Accident and Emergency Department of Tameside General Hospital. She was seen in triage promptly and the inquest heard that the fact of her anticoagulant medication was noted and in consequence, because of the head injury, a CT scan was ordered at triage stage, rather than awaiting review by a doctor: The CT scan was performed at 12.07pm, but before the CT scan was reviewed by the A&E Consultant at the time of his examination of Mrs Waterfall at about 1.1Opm, Mrs Waterfall's condition deteriorated: The CT scan showed a subdural haematoma and she was moved to the resuscitation unit: After consultation with a neurosurgeon at Salford Roval Hospital and the haematologist at Tameside General Hospital and the decision was made to administer Prothrombin complex as an antidote to the Edoxaban: inquest heard that Edoxaban has no currently licensed antidote: Prothrombin complex is not specific to Edoxaban and its effectiveness is difficult to assess and monitor: The

Mrs Waterfall did not respond to the Prothrombin complex and her condition was such that when the second CT scan was reviewed, there was no surgical intervention which would have been viable ad she was moved to the intensive care unit at Tameside General Hospital: Whilst she had a period of brief raised consciousness the following her condition did not improve and she was transferred with the agreement of her family to Willow Wood Hospice on 15th where she remained until her death on 26t July 2019. A post mortem examination concluded that Mrs Waterfall died as a consequence of: 1Ja) Subdural haematoma

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action;