First reported 5 Sep 2013•Latest report 28 May 2026
Definition
What this concern includes
Includes failures of controls specifically dedicated to anticoagulant management, including prescribing clarity and reconciliation, anticoagulation-chart accuracy, INR or other required monitoring, senior clinical review, risk-sensitive guidance, escalation and consideration of anticoagulant treatment in relevant clinical circumstances.
Not included
Excludes generic medication-prescribing, record-keeping, staffing, training or communication deficiencies unless they are specifically tied to anticoagulant management.
Excludes general bleeding-risk controls for patients taking antithrombotic medication when the assertion does not concern anticoagulant management itself.
Excludes medication administration, supply or continuity failures where anticoagulant treatment management is not the identified unsafe condition.
Excludes unrelated thromboprophylaxis, venous-thromboembolism prevention and non-anticoagulant medication concerns.
Reports
25
Distinct published reports
Individual concerns
34
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
28
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 Excellence5
NHS England4
Cwm Taf Morgannwg University Local Health Board3
Department of Health and Social Care3
Recipient name withheld3
Senedd Cymru3
Welsh Government3
Aneurin Bevan University LHB1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Barnsley Hospital NHS Foundation Trust1
Birmingham Women'S and Children'S NHS Foundation Trust1
British Cardiovascular Society1
Care Quality Commission1
East Kent Hospitals University NHS Foundation Trust1
Frimley Health NHS Foundation Trust1
NHS trust15
Executive non-departmental public body7
Healthcare site5
Devolved government3
Devolved legislature3
Local health board3
Ministerial department3
Type not available3
Coronial office1
Health and social care service regulator1
Health professional body1
Health-system partnership1
Integrated care board1
Nursing home1
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.
Essex
Concerns raised2
Lack of General Practitioner funding for at-home anticoagulation testing supplies
Use of alternative anticoagulation medication associated with high INR readings and bleeding risk
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Establish an escalation process for clinically required anticoagulation monitoring equipment or consumables when financial barriers arise, including funding guidance, staff communication and application audits.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 August 2026.
Action
Introduce documented senior-clinician and, where appropriate, haematology review requirements, an updated operating procedure, staff communication and governance audits for complex anticoagulation cases.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Commissioning responsibility for at-home INR monitoring rests with Integrated Care Boards, varying according to the clinical pathway and service specification.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Long-term additional injections were not clinically appropriate after alternative anticoagulation regimens had been trialled.
Stated by Mid and South Essex NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Berkshire
Concerns raised1
Failure of the post-falls proforma to prompt consideration of anticoagulation reversal and urgency
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised1
Lack of an evidence-based protocol for withholding or reversing DOAC and prescribing alternative anticoagulant medication
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Continue monitoring new evidence on DOAC anticoagulation decisions.
Stated by National Institute for Health and Care ExcellenceStated in progressThe respondent said that this action was in progress when they made their response on 4 July 2024.
Action
Develop or update NICE guidance on DOAC anticoagulation decisions in response to new evidence.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 4 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NICE cannot develop useful guidance on DOAC reversal decisions because high-quality evidence is lacking and decisions require individual clinical judgement.
Stated by National Institute for Health and Care ExcellenceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Leicester City and South Leicestershire
Concerns raised1
Failure to communicate all relevant patient information to doctors dosing warfarin
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Re-emphasised clear anticoagulation communication, shared case learning with clinical leaders and forums, and delivered repeated daily-brief reminders to clinical teams.
Stated by University Hospitals of Leicester NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2024.
Action
Embed a digital reminder requiring MDT colleagues to record pertinent clinical information and patient-condition changes in digital warfarin dosage requests.
Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 28 June 2024.
Warwickshire
Concerns raised1
Failure to coordinate pericardiocentesis timing with the duration of DOAC interruption
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Operational responsibility for delivering health services and responding to related concerns lies with NHS England.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Failure to provide recommendations for discussing anticoagulation withholding risks and benefits with patients
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Assess the issue through the guidelines surveillance process to determine whether guidance recommendations should be updated or newly issued.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 14 August 2024.
North East Kent
Concerns raised1
Failure to record reasons for not following Consultant Haematologist anticoagulation advice
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Communicate to clinical teams the requirement to document decision-makers and rationales when withholding haematology-advised anticoagulant treatment.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 October 2022.
Essex
Concerns raised1
Lack of a local protocol for managing anticoagulated patients over 65 receiving treatment-dose clexane who sustain head trauma
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Establish a multidisciplinary task and finish group to review and improve anticoagulation and falls protocols.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.
Action
Update, approve and distribute falls policies and post-fall guides covering anticoagulation decisions, observation requirements and documented action plans.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.
Action
Amend Nerve Centre to require completion of every section of neurological observations and communicate the change to ward leaders.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.
Action
Make falls prevention and management training mandatory for clinical staff and incorporate the updated anticoagulation and neurological observation requirements.
Stated by the Princess Alexandra Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 December 2020.
Nottinghamshire
Concerns raised2
Multiple charts and documents permitting muddled or omitted anticoagulant prescribing
Lack of senior review of patients for anticoagulant management
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Complete a multidisciplinary review of the warfarin prescribing, dosing and supporting-documentation process.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 November 2020.
Action
Document decisions to change existing warfarin plans on the yellow dosing chart and in the clinical record when made.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 November 2020.
Action
Require senior-doctor discussion and full documentation before changing an existing warfarin plan.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 November 2020.
Action
Explore electronic Nervecentre alerts to inform ward doctors when INR results become available.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 November 2020.
Action
Consider adding prompts to warfarin documentation addressing thrombosis and bleeding risks during prescribing decisions.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 November 2020.
Action
Disseminate guidance reminding staff to amend both charts when withholding warfarin doses.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 November 2020.
Action
Include the patient story in junior-doctor training on warfarin prescribing errors.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 November 2020.
Action
Audit compliance with documentation requirements for the immediate warfarin safety actions.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 November 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The expert panel concluded that changing the entire warfarin prescription process would be unlikely to prevent future deaths and could increase prescribing errors.
Stated by Sherwood Forest Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Paper documentation changes could not realistically complete governance and printing processes before electronic prescribing was piloted.
Stated by Sherwood Forest Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised2
Lack of a national protocol for timely anticoagulant antidote administration
Lack of a clear target time for anticoagulant antidote administration
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of controls specifically dedicated to anticoagulant management, including prescribing clarity and reconciliation, anticoagulation-chart accuracy, INR or other required monitoring, senior clinical review, risk-sensitive guidance, escalation and consideration of anticoagulant treatment in relevant clinical circumstances.
