Recurring concern

Inadequate controls for bleeding risk in patients taking antithrombotic medication

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First reported 2 Jul 2014•Latest report 24 Apr 2024

Definition

What this concern includes

Includes failures of a clinical guidance, pathway, protocol or assessment control specifically intended to prevent, detect, assess or respond to bleeding risk in patients taking antiplatelet or anticoagulant medication, including omitted medication-sensitive checks or risk triggers.

Not included

  • Excludes generic failures in training, documentation, staffing or clinical assessment that are not specifically tied to bleeding risk from antithrombotic medication.
  • Excludes bleeding risks arising solely from unrelated medical conditions, procedures or hazards without an antiplatelet or anticoagulant medication qualifier.
  • Excludes failures concerning treatment of an established bleed where the report does not identify inadequate control of medication-associated bleeding risk.
Reports
10

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
7

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

National Institute for Health and Care Excellence3
International Academies of Emergency Dispatch2
Alexander House Health Centre1
Blackpool Teaching Hospitals NHS Foundation Trust1
Department of Health and Social Care1
East Kent Hospitals University NHS Foundation Trust1
Glenroyd Medical Centre1
Greater Manchester Health and Social Care Partnership1
Greater Manchester Mental Health NHS Foundation Trust1
Hc-One Limited1
Scottish Dental Clinical Effectiveness Programme1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Derby and Derbyshire

    AI-generated summary

    Derek HAND · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Derek HAND experienced continued bleeding after a tooth extraction while taking Clopidogrel, lost consciousness, and was admitted to hospital. Although his condition initially improved, he later developed swallowing difficulties and aspiration pneumonia, deteriorated, and died on end-of-life care. The principal concern was whether current guidance should require blood testing before dental procedures for patients taking Clopidogrel to identify a risk of excess bleeding.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to require clotting-function checks for patients taking Clopidogrel before dental procedures

    Wider context from the report

    “The NHS Education for Scotland Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs states that for patients on Clopidogrel dental treatment can occur without interrupting medication. This is in contrast to, for example, patients on Warfarin, who are required to have an INR test prior to any procedure. Mr Hand's tooth extraction was performed as per the current guidance. As he was on Clopidogrel the procedure was carried out with no further checks being carried out as to his clotting function. Following the tooth extraction the site continued to bleed, to the extent that Mr Hand lost consciousness, required hospital admission and subsequently developed aspiration pneumonia. My concern is that as the current guidance does not require any further checks for patients on Clopidogrel prior to dental procedures there is a risk of other patients on Clopidogrel experiencing excess bleeding following dental procedures. It would be of assistance to know whether: a. Has any thought been given to requiring an INR test or any other form of blood test to detect a risk of excess bleeding for patients on Clopidogrel prior to dental procedures? b. If it has not, is there a reason for this? ”

    Source location

    Derek HAND · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider blood tests for detecting excess bleeding risk during development of antiplatelet-drug dental guidance.

    Verbatim wording from the response

    “In response to the queries from the Assistant Coroner, SDCEP can confirm that blood tests to detect a risk of excess bleeding for patients taking clopidogrel or other antiplatelet drugs were considered during the development of the Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs guidance. Based on expert clinical opinion and published advice, the guidance notes in Section 8 that “There is no suitable test equivalent to the INR for measuring the antiplatelet effect of the various drugs that patients may be taking.””

    Source location

    Response from NHS Education for Scotland
    Page 2 · response
    Published 31 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the guidance in 2027 and consider new evidence or expert clinical opinion concerning bleeding-risk testing for patients taking clopidogrel or other antiplatelet drugs.

    Verbatim wording from the response

    “The next review of the guidance is scheduled to commence in 2027. However, if SDCEP becomes aware of any significant developments before the scheduled review, an earlier review may be triggered. During the scheduled review, any new evidence or changes in expert clinical opinion relating to the Assistant Coroner’s concerns will be considered to check whether the situation has changed.”

    Source location

    Response from NHS Education for Scotland
    Page 2 · response
    Published 31 October 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No available blood test reliably predicts excessive bleeding risk in patients taking clopidogrel, so a pre-procedure test cannot be required.

    Verbatim wording from the response

    “In response to the queries from the Assistant Coroner, SDCEP can confirm that blood tests to detect a risk of excess bleeding for patients taking clopidogrel or other antiplatelet drugs were considered during the development of the Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs guidance. Based on expert clinical opinion and published advice, the guidance notes in Section 8 that “There is no suitable test equivalent to the INR for measuring the antiplatelet effect of the various drugs that patients may be taking.””

    Source location

    Response from NHS Education for Scotland
    Page 2 · response
    Published 31 October 2024

    Open published response

  2. Dorset

    AI-generated summary

    Kenneth Michael Adams · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kenneth Michael Adams suffered a scalp laceration after an accidental fall on 19 October 2021. He experienced persistent bleeding while taking clopidogrel, but an ambulance did not arrive until 11.56am; he later died in hospital. The principal concerns were that the Medical Priority Despatch System did not adequately account for persistent scalp bleeding, the high blood flow in the scalp, or antiplatelet medication when prioritising the ambulance response.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of MPDS to account for anticoagulant or antiplatelet medication

    Wider context from the report

    “1. During the inquest evidence was heard that: i. A patient, prescribed either antiplatelet or anticoagulant medication, falling and sustaining a scalp laceration that is not “spurting or pouring blood” (the MPDS definition of “uncontrolled bleeding”), will never reach an MPDS disposition that results in a prioritisation higher than category 3, regardless of how long the bleeding has been persisting, unless the patient becomes unconscious or stops breathing. I heard evidence that the scalp is an area of high venous blood flow, such that a laceration to the scalp is capable of bleeding significantly. However, because of the nature of the blood supply in this area, the wound will not “spurt or pour” blood, so with the current iteration of MPDS a wound in this area of the body can never be considered as “serious haemorrhage”. Despite this, when assessing the seriousness of a bleed that does not meet the criteria for a “serious haemorrhage”, the MPDS algorithm does not allow for consideration of any delay in treatment or for the consideration of medications that may either exacerbate the extent of a bleed or prevent the blood from clotting to stop the bleed. For a patient such as Mr Adams, prescribed antiplatelet medication, there is a considerable risk that the bleeding will persist until the wound is closed, such that a delay in receiving treatment, where the wound continues to bleed, leaves the patient at risk of developing hypovolaemic shock. 2. I have concerns with regard to the following: i. Where a patient on anticoagulant or antiplatelet therapy sustains a fall and scalp laceration, the questions forming the MPDS protocol designed to assess the seriousness of the bleed and the prioritisation of an ambulance resource do not allow for consideration of the period of the time the bleeding has persisted from an area of high vascular blood flow or the medication prescribed. Therefore, in circumstances where the bleeding has persisted for a considerable time and where there is no evidence of the bleeding stopping, it seems the MPDS disposition reached would always be 17-b-01, with a consequent category 3 priority, which does not account for the increasing seriousness of the patient’s predicament and the potential consequences of the continued blood loss. ”

    Source location

    Kenneth Michael Adams · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Study the potential impact of uniquely coding patients taking anticoagulant or antiplatelet medication who have active bleeding or closed head injuries.

    Verbatim wording from the response

    “4. The IAED is currently studying the potential impact of the unique coding of patients who are taking anticoagulant/antiplatelet medication (blood thinners) who have active bleeding or closed head injuries. Due to the relatively high number of patients receiving this therapy * as compared to the number of patients who are at risk of a poor outcome related to that therapy, there is significant risk of over-triage, which may only make matters worse in areas with limited resources. Another consideration is that those patients who do not meet these criteria will inevitably suffer even longer wait times as a result. *Preliminary data suggests that nearly 22 percent of all patients with a chief complaint of hemorrhage are on blood thinners (30 percent of those aged 60-75 and 41 percent aged 75-90).”

    Source location

    Response from International Academics of Emergency Dispatch
    Page 3 · response
    Published 24 March 2023

    Open published response

  3. South Yorkshire (Western)

    AI-generated summary

    Roy Middleton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roy Middleton fell at home on 9 February 2022, sustaining a head injury while taking warfarin. Emergency medical assistance arrived more than six hours after the initial call, and he died in hospital on 10 February 2022 from a traumatic acute subdural haemorrhage. The principal concern was that the emergency dispatch algorithm did not take anticoagulant medication into account when determining the response category for a head injury.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the emergency dispatch algorithm to account for anticoagulant medication in head injury patients

    Wider context from the report

    “The inquest heard that the International Academies of Emergency Dispatch system algorithm does not take into account whether a patient is on blood thinning medication when considering the category of emergency response required. The inquest also heard from a consultant geriatrician that “by the time he arrived at the hospital he was not fit for any intervention”. I am concerned that if the algorithm isn’t changed to take into account the affect of anti-coagulant medication on a head injury, deaths will occur in the future. ”

    Source location

    Roy Middleton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Maureen Waterfall · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Maureen Waterfall fell at home on 12 July 2019 while taking the anticoagulant Edoxaban and sustained a head injury that led to a subdural haematoma. She died at Willow Wood Hospice on 26 July 2019. Concerns included the lack of a licensed specific antidote for Edoxaban, uncertainty about treatment effectiveness and timing, the absence of national guidance, and the storage of antidote supplies away from the resuscitation unit.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a clear target time for anticoagulant antidote administration

    Wider context from the report

    “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients. The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations. ”

    Source location

    Maureen Waterfall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Blackpool and the Fylde

    AI-generated summary

    Frank Raymond STOCKTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Frank Raymond Stockton was admitted to hospital with shortness of breath and collapse, later experienced recurrent nosebleeds while receiving oxygen therapy and Warfarin, and died on 22 July 2018 after developing melena and haematemesis. The principal concern was that the risks of epistaxis causing or contributing to death, particularly in patients receiving oxygen therapy or Warfarin or with impaired lung or heart function, may not be generally recognised by clinicians, and that maintaining the INR within its target range may not prevent this risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clinician awareness of the fatal risks of epistaxis in patients receiving oxygen therapy, taking Warfarin, or with impaired lung or heart function

    Wider context from the report

    “(1) It was the evidence of a number of clinicians who gave evidence in the course of the inquest that they had not come across a death occasioned by epistaxis in the course of their clinical careers. In those circumstances the cause of the deceased’s death may have been unusual. In that regard he received oxygen therapy both in hospital and, following discharge, at home through a nasal cannula and was also prescribed Warfarin on account of his atrial fibrillation. Whilst, for much of the period in question his Internationalised Normalised Ratio fell within the target range of 2.0 – 3.0 he developed epistaxis which, in the context of and in combination with compromised lung and heart function due to pulmonary fibrosis and ischaemic heart disease, caused his death. In the course of preparing statements for the purpose of the inquest 2 practitioners did not identify and/or did not identify the significance of 2 references to nosebleeds (epistaxis) (or the possibility thereof) within the clinical records. Thus the concern arises that (1) the risks of epistaxis causing or contributing to death, particularly in a patient who is receiving oxygen therapy and/or who is taking Warfarin and/or who has underlying conditions which impair lung and/or heart function and (2) the fact that the risk of death may not be avoided merely on account of the maintenance of a patient’s Internationalised Normalised Ratio within a target range may not be known generally amongst clinicians such that circumstances creating a risk of other deaths will occur or will continue to exist in the future. ”

    Source location

    Frank Raymond STOCKTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Colin Bailey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Colin Bailey was admitted to hospital following a stroke and later transferred for rehabilitation. After falling and hitting his head while taking anticoagulant medication, he suffered an extensive subarachnoid haemorrhage and died at Tameside General Hospital on 10 April 2018. The concern was that national guidance did not require a CT scan in this situation for all types of anticoagulant medication, although clinicians indicated that scanning should be undertaken regardless of the type used.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to undertake CT brain/head scans after falls with head impact in patients taking anticoagulant medication

    Wider context from the report

    “The inquest heard that Mr Bailey fell and hit his head whilst an in-patient at Stepping Hill hospital. No CT scan of the brain/head was undertaken despite Mr Bailey taking anti-coagulant medication because NICE guideline recommended a scan is undertaken if the patient has fallen, struck their head and is taking warfarin but that is not the guidance if the anticoagulant medication is one of the other types of anticoagulant medications used. The clinicians attending the Inquest indicated that a CT scan in this scenario should be undertaken whatever the type of anti-coagulant medication and that is the Trust's own policy going forwards. There was concern that this ought to be national guidance. ”

    Source location

    Colin Bailey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of national guidance on CT scanning after falls with head impact in patients taking different types of anticoagulant medication

    Wider context from the report

    “The inquest heard that Mr Bailey fell and hit his head whilst an in-patient at Stepping Hill hospital. No CT scan of the brain/head was undertaken despite Mr Bailey taking anti-coagulant medication because NICE guideline recommended a scan is undertaken if the patient has fallen, struck their head and is taking warfarin but that is not the guidance if the anticoagulant medication is one of the other types of anticoagulant medications used. The clinicians attending the Inquest indicated that a CT scan in this scenario should be undertaken whatever the type of anti-coagulant medication and that is the Trust's own policy going forwards. There was concern that this ought to be national guidance. ”

    Source location

    Colin Bailey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Portsmouth and South East Hampshire

    AI-generated summary

    Thelma Doris Clarkson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thelma Doris Clarkson fell at home on 10 February 2015, sustained head injuries, and died in hospital the following day after her condition deteriorated and an inoperable head injury was identified. The concern was that the NICE Head Injury Pathway did not treat Clopidogrel use as a trigger for a CT scan in the same way as Warfarin, despite the risk of increased bleeding from head trauma.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the head injury pathway to include Clopidogrel as a CT scan trigger

    Wider context from the report

    “Prior to her fall, Mrs Clarkson has for some time been prescribed and was taking the drug Clopidogrel for long-standing heart disease. The British National Formulary warns that patients taking Clopidogrel are at risk of increased bleeding from trauma. However, I was told in evidence at the Inquest that under the NICE Head Injury Pathway which was in use at the time at Gosport War Memorial Hospital, had Mrs Clarkson been taking Warfarin she would have been sent to a larger hospital to have a CT scan of her head but the Pathway did not include Clopidogrel as a similar trigger for a CT scan - notwithstanding the risk of increased bleeding from head trauma. I was also told that, had Mrs Clarkson been sent from Gosport War Memorial Hospital for a CT scan, there is a strong possibility it would have revealed the extent of her head injury and her treatment - and its potential outcome - may have been different. I am therefore concerned that the NICE should consider whether its Head Injury Pathway should be amended to include taking Clopidogrel as a trigger for a CT scan in the same way as Warfarin presently does. ”

    Source location

    Thelma Doris Clarkson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Manchester West

    AI-generated summary

    Dorothy Delaney · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dorothy Delaney was found collapsed at her care home on 11 June 2015 after being prescribed Rivaroxaban for atrial fibrillation and Clopidogrel for previous transient ischaemic attacks. She was diagnosed with a large intracerebral haemorrhage and died later that day. The principal concern was that both anticoagulant and antiplatelet medications were prescribed without individual specialist advice, increasing the risk of haemorrhage.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain individualized specialist advice for patients prescribed anticoagulation and antiplatelet medication together

    Wider context from the report

    “vi. Following Mrs Delaney’s diagnosis of atrial fibrillation and the subsequent prescription of Rivaroxaban, no specialist advice was sought regarding the appropriateness of continuing to prescribe both Clopidogrel and Rivaroxaban together. Evidence was given at the inquest that advice is not sought on an individual basis for patients at Alexander House Health Centre who are prescribed both Clopidogrel and Rivaroxaban as they rely on advice previously sought in respect of other patients in similar circumstances. 2. I therefore have concerns that there are patients under the care of Alexander House Health Centre who are being prescribed both anticoagulation therapy and antiplatelet medication at the same time, which increases the risk of a haemorrhage occurring, in circumstances where specialist advice has not been sought, taking into account the individual patient’s previous medical history and circumstances. ”

    Source location

    Dorothy Delaney · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Produce a practice protocol for prescribing anticoagulant and antiplatelet medicines together.

    Verbatim wording from the response

    “Although I was not able to find any protocol or guidance on this issue, as I have feedback from our local Haematology Department, I decided to produce a protocol for our practice for future prescribing of anticoagulant with antiplatelet agents. Furthermore I have reviewed all the patients who are on combined treatment. I have looked at their medical records and checked the suitability of the patient to be on both groups of medication. In any patient, if I was not sure, I have liaised with secondary care to clarify the matter.”

    Source location

    2015-0402-Alexander-House-Health-Centre
    Page 2 · response
    Published 23 September 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review all patients receiving combined anticoagulant and antiplatelet treatment, checking documented suitability and consulting secondary care when uncertain.

    Verbatim wording from the response

    “Although I was not able to find any protocol or guidance on this issue, as I have feedback from our local Haematology Department, I decided to produce a protocol for our practice for future prescribing of anticoagulant with antiplatelet agents. Furthermore I have reviewed all the patients who are on combined treatment. I have looked at their medical records and checked the suitability of the patient to be on both groups of medication. In any patient, if I was not sure, I have liaised with secondary care to clarify the matter.”

    Source location

    2015-0402-Alexander-House-Health-Centre
    Page 2 · response
    Published 23 September 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Change prescriptions to single anticoagulant treatment where appropriate after discussing the decision with each patient.

    Verbatim wording from the response

    “I felt on reviewing their records, most of the patients could be managed by a singly anticoagulant agent instead of combined treatment, as per our local Haematology guidance. Accordingly I made the”

    Source location

    2015-0402-Alexander-House-Health-Centre
    Page 2 · response
    Published 23 September 2015

    Open published response

  9. Central and South East Kent

    AI-generated summary

    Patricia Anne HOLMES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Patricia Anne Holmes was diagnosed with fractured ribs at William Harvey Hospital on 1 February 2015 and, despite information that she was receiving anticoagulation therapy with an INR of 6, no action was taken to reverse its effect. She returned in a state of collapse on 2 February and died two days later; the principal concern was that the treating A&E doctor did not consider the risk of internal bleeding associated with her trauma, rib fractures and anticoagulation therapy.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consider necessary action in light of trauma, multiple fractured ribs and anticoagulation-related internal bleeding risk

    Wider context from the report

    “The staff grade A&E doctor who treated Mrs Holmes on 1 February did not consider what action was necessary given the history of trauma and multiple fractured ribs on x-ray and that she was at risk of internal bleeding since she was receiving anticoagulation therapy. ”

    Source location

    Patricia Anne HOLMES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the approved Chest Trauma Algorithm across the Trust’s emergency departments to guide triage, assessment, treatment, anticoagulation reversal and haematology advice.

    Verbatim wording from the response

    “Prior to the inquest being resumed, the Trust had already disclosed to you a draft Chest Trauma Algorithm and this has been approved and is now in place throughout the emergency departments of the Trust. The aim of the Algorithm is to safely triage, assess and treat patients who present with chest trauma. It has been designed to consider the reversal of anticoagulation, Box 1, of the Algorithm specifically directs the reader to consider the reversal of anticoagulation and to seek expert advice from the Trust's haematologists upon advice from the haematology committee on treatment within the Algorithm.”

    Source location

    2015-0254-Response-by-East-Kent-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 2 July 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    An existing trauma protocol is considered more appropriate than a medication-specific anticoagulation pathway.

    Verbatim wording from the response

    “Within your Regulation 28 Report dated 29 June 2015 you recommended that the Trust should have a protocol in place for the use of an anticoagulation pathway in all cases where a patient has sustained trauma and is in receipt of this type of medication. In view of the importance of maintaining clinical trauma and in respect of this type of medication, the Trust has a protocol which is used to assist and guide the management of patients with trauma. This is more appropriate than a protocol related to a specific type of medication.”

    Source location

    2015-0254-Response-by-East-Kent-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 2 July 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing mitigation focuses on chest injuries rather than extending the response to all trauma-related injuries.

    Verbatim wording from the response

    “Mrs Holmes' case related to a chest trauma and the effects of the anticoagulant medication (Acenocoumarol) with her injuries. The Emergency Department and Surgical staff have therefore looked at mitigating similar events for future patients who present with chest injuries rather than all trauma-related injuries.”

    Source location

    2015-0254-Response-by-East-Kent-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 2 July 2015

    Open published response

  10. Manchester South

    AI-generated summary

    ALBERT FLYNN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Albert Flynn, a resident of Appleton Manor Residential Home, was taken to hospital with a suspected deep vein thrombosis and treated with the blood-thinning drug Enoxaparin. The following night he was left in a chair for approximately 10 hours without food, fluids or prescribed medication, while staff were unable to rouse him. He was suffering from a severe cerebral bleed, which was fatal; concerns included inadequate staff training and failure to recognise the significance of his condition and recent blood-thinning treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to account for recent blood-thinning medication in assessment

    Wider context from the report

    “1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated. 2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours. 3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event, nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day. 4. The staff did not seem to appreciate the importance of administering prescribed medication. ”

    Source location

    ALBERT FLYNN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Qualified nursing input for residential clients would normally be provided by the district nursing service, rather than residential care staff.

    Verbatim wording from the response

    “Mr Flynn’s condition should have been addressed at that stage. The nurse on duty would then have been able to attribute proper weight to the fact that Mr Flynn had received blood thinning drugs the previous day and his state of consciousness was cause for concern. The hospital did not provide any cautionary advice for the care team upon discharge back to the home on the evening of 14th March 2014 following the administration of anti-coagulation therapy, nor did the hospital initiate district nursing input across the weekend. Mr Flynn was accommodated as a residential client and so his day to day care would not have been provided by qualified nurses but by care assistants. The nursing input would normally be provided by the district nursing service.”

    Source location

    2014-0308-Response-by-Lester-Aldridge-LLP
    Page 2 · response
    Published 2 July 2014

    Open published response
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Data last updated 7 September 2026