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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 25 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked responses
Mid and South Essex NHS Foundation Trust
NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Mid and South Essex NHS Foundation Trust
Establish an escalation process for clinically required anticoagulation monitoring equipment or consumables when financial barriers arise, including funding guidance, staff communication and application audits.
Mid and South Essex NHS Foundation Trust
Introduce documented senior-clinician and, where appropriate, haematology review requirements, an updated operating procedure, staff communication and governance audits for complex anticoagulation cases.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
NHS England
Commissioning responsibility for at-home INR monitoring rests with Integrated Care Boards, varying according to the clinical pathway and service specification.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Mid and South Essex NHS Foundation Trust
Long-term additional injections were not clinically appropriate after alternative anticoagulation regimens had been trialled.
Unable 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.
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
Linked response
National Institute for Health and Care Excellence
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
National Institute for Health and Care Excellence
Continue monitoring new evidence on DOAC anticoagulation decisions.
National Institute for Health and Care Excellence
Develop or update NICE guidance on DOAC anticoagulation decisions in response to new evidence.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
National Institute for Health and Care Excellence
NICE cannot develop useful guidance on DOAC reversal decisions because high-quality evidence is lacking and decisions require individual clinical judgement.
Unable 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.
Linked response
University Hospitals of Leicester NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
University Hospitals of Leicester NHS Trust
Re-emphasised clear anticoagulation communication, shared case learning with clinical leaders and forums, and delivered repeated daily-brief reminders to clinical teams.
University Hospitals of Leicester NHS Trust
Embed a digital reminder requiring MDT colleagues to record pertinent clinical information and patient-condition changes in digital warfarin dosage requests.
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.
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
Operational responsibility for delivering health services and responding to related concerns lies with NHS England.
Redirects 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.
Linked response
National Institute for Health and Care Excellence
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
National Institute for Health and Care Excellence
Assess the issue through the guidelines surveillance process to determine whether guidance recommendations should be updated or newly issued.
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.
Linked response
East Kent Hospitals University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
East Kent Hospitals University NHS Foundation Trust
Communicate to clinical teams the requirement to document decision-makers and rationales when withholding haematology-advised anticoagulant treatment.
Essex
Concerns raised1
Lack of a local protocol for managing anticoagulated patients over 65 receiving treatment-dose clexane who sustain head trauma
Linked response
the Princess Alexandra Hospital NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
the Princess Alexandra Hospital NHS Trust
Establish a multidisciplinary task and finish group to review and improve anticoagulation and falls protocols.
the Princess Alexandra Hospital NHS Trust
Update, approve and distribute falls policies and post-fall guides covering anticoagulation decisions, observation requirements and documented action plans.
the Princess Alexandra Hospital NHS Trust
Amend Nerve Centre to require completion of every section of neurological observations and communicate the change to ward leaders.
the Princess Alexandra Hospital NHS Trust
Make falls prevention and management training mandatory for clinical staff and incorporate the updated anticoagulation and neurological observation requirements.
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.
Linked response
Sherwood Forest Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Sherwood Forest Hospitals NHS Foundation Trust
Complete a multidisciplinary review of the warfarin prescribing, dosing and supporting-documentation process.
Sherwood Forest Hospitals NHS Foundation Trust
Document decisions to change existing warfarin plans on the yellow dosing chart and in the clinical record when made.
Sherwood Forest Hospitals NHS Foundation Trust
Require senior-doctor discussion and full documentation before changing an existing warfarin plan.
Sherwood Forest Hospitals NHS Foundation Trust
Explore electronic Nervecentre alerts to inform ward doctors when INR results become available.
Sherwood Forest Hospitals NHS Foundation Trust
Consider adding prompts to warfarin documentation addressing thrombosis and bleeding risks during prescribing decisions.
Sherwood Forest Hospitals NHS Foundation Trust
Disseminate guidance reminding staff to amend both charts when withholding warfarin doses.
Sherwood Forest Hospitals NHS Foundation Trust
Include the patient story in junior-doctor training on warfarin prescribing errors.
Sherwood Forest Hospitals NHS Foundation Trust
Audit compliance with documentation requirements for the immediate warfarin safety actions.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Sherwood Forest Hospitals NHS Foundation Trust
The expert panel concluded that changing the entire warfarin prescription process would be unlikely to prevent future deaths and could increase prescribing errors.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Sherwood Forest Hospitals NHS Foundation Trust
Paper documentation changes could not realistically complete governance and printing processes before electronic prescribing was piloted.
Unable 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.