Recurring concern

Unsafe anticoagulant management

First to latest report 5 Sep 2013 — 28 May 2026

Reports that mention this concern
25
Times this concern has been raised
34
Stated actions linked to this concern
28

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.

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.

Reports and published responses 25 reports

See individual reports that have raised this concern, and the actions taken in response

  1. North London

    AI-generated summary

    Amanda Susan Harris · 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

    Amanda Susan Harris fell at her care home, fractured a bone in her right foot, and died in bed on 1 November 2014 after being unable to get out of bed. Concerns included that she was not seen by a doctor before leaving the Minor Injuries Unit, anticoagulant therapy was not considered, and the effects of potential immobility were not assessed when arranging her fracture-clinic appointment.

    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 anticoagulant therapy

    Wider context from the report

    “That Mrs Harris was not seen by a doctor before leaving the Minor Injuries Unit, that anticoagulant therapy was not considered and that when fixing an appointment for the fracture clinic the potential immobility from the injury and the effects of that immobility were not assessed. ”

    Source location

    Amanda Susan Harris · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mrs. Hilda May Harris · 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

    Mrs. Hilda May Harris, aged 86, suffered a cerebral infarction with an intracerebral haemorrhage on 04.01.15 after an additional INR test was not undertaken while she was taking Warfarin alongside medication for gout. The report identified unreliable systems for booking community INR tests and for notifying or acting on omissions.

    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

    Unreliable booking system for community INR testing

    Wider context from the report

    “(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another. (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable. ”

    Source location

    Mrs. Hilda May Harris · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Black Country

    AI-generated summary

    Mr Ward · 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

    Mr Ward, an 85-year-old care home resident taking warfarin, suffered an unwitnessed fall and head injury on 29 November 2014. He was found unresponsive the following morning and died on 11 December 2014 after a CT confirmed a subdural haematoma. Concerns included staff awareness of the increased bleeding risk associated with head injury while taking warfarin, and the lack of clear policy, training, and escalation procedures for such falls.

    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 clear policy or training for dealing with patients on anticoagulant therapy

    Wider context from the report

    “(1) Mr Ward was an elderly patient who was at risk of falling and who was on long term warfarin. There is an increased risk of bleeding to elderly patients on warfarin who sustain a head injury. The care staff who attended to Mr Ward appeared to be unaware of the increased risk of bleeding even though there weren’t visible injuries. (2) During the inquest evidence was given in relation to the fall risk assessment and the policy adopted. However, there was no clear policy or training highlighted in dealing with patients who are on anti-coagulant therapy. In addition, it wasn’t clear the procedure for the escalation and referral of patients to qualified medical staff in the event of a fall. ”

    Source location

    Mr Ward · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Nottinghamshire

    AI-generated summary

    Phyllis Kerry · 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

    Phyllis Kerry, who was taking long-term Warfarin, was admitted with symptoms suggestive of stroke and found to have a haemorrhagic stroke. She deteriorated and died after the intracerebral bleed increased. The principal concerns were uncertainty about which specialty was responsible for deciding on immediate Warfarin reversal, the absence of clear guidelines, and inadequate communication of relevant guidelines to staff.

    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

    Absence of clear guidelines for managing patients with intra-cerebral bleeds while on Warfarin or similar medication

    Wider context from the report

    “(1) Which specialty takes responsibility for deciding when immediate reversal is needed? (2) The absence of clear guidelines for dealing with patients presenting with intra-cerebral bleeds whilst on Warfarin or similar medication. (3)The communication of relevant guidelines to relevant staff. While none of the witnesses I heard from were aware of any relevant guidelines, it is possible that these may in fact already be in existence. Similarly, it may be that draft guidelines are being reviewed. However it was not clear from the evidence when / if these would be finalised. If there are existing guidelines, it would concern me greatly that the witnesses I heard from were unaware of these, and I take the view that communication of guidelines is as important as the guidelines themselves. ”

    Source location

    Phyllis Kerry · 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

    Agree a guideline for prompt treatment of warfarin patients presenting with intracranial haemorrhage.

    Verbatim wording from the response

    “The new guideline to assist with the prompt and appropriate treatment of patients who are on warfarin presenting with Intra Cranial Haemorrhage has now been agreed by all parties involved and accompanies this letter.”

    Source location

    2014-0457-Response-by-Nottingham-University-Hospitals-NHS-Trust2f
    Page 1 · response
    Published 23 October 2014

    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

    Finalise a cross-specialty guideline clarifying anticoagulation reversal responsibility and enabling rapid intervention.

    Verbatim wording from the response

    “A new guideline has been prepared which I am confident will provide more rapid intervention in the management of anticoagulation and will clarify which specialty is responsible for this element of care.”

    Source location

    2014-0457-Response-by-Nottingham-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 23 October 2014

    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

    Share the agreed guideline with relevant medical staff and add it to the NUH guideline app.

    Verbatim wording from the response

    “In addition to sharing with medical staff in the appropriate specialties we will also ask for this guideline to be added to the NUH guideline APP which will assist medical staff to access the guideline whenever required.”

    Source location

    2014-0457-Response-by-Nottingham-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 23 October 2014

    Open published response

  5. Leicester City and South Leicestershire

    AI-generated summary

    Labuben Amarsi Vaghadia · 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

    Mrs Vaghadia developed bleeding after receiving an anticoagulant injection for suspected deep vein thrombosis and died in hospital on 27 August 2012 from haemorrhage and haematoma of the abdominal wall. Concerns included the community nurse administering a further anticoagulant injection without seeking medical advice despite knowing about the bleeding, failing to share that information with other healthcare professionals, and lacking training, experience, and insight into the potential risks of her actions.

    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 seek medical advice before administering anticoagulants despite known bleeding

    Wider context from the report

    “(1) Community Nurse ████████ administered the anticoagulant on the 26th August 2012 without seeking medical advice from a Doctor even though she knew Mrs Vaghadia had been bleeding from the site of the previous injection. Although the expert evidence in this case is that the nurse’s actions did not cause or contribute to the death in this instance, there is a risk that such action in another case may not have the same outcome and could be causative of death. ”

    Source location

    Labuben Amarsi Vaghadia · 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

    Re-inform CHS healthcare professionals about medicines-management standards, communication responsibilities, relevant case learning, and the community medicines SOP through email cascades, briefings, meetings, and SOP reissue.

    Verbatim wording from the response

    “It is accepted fully that part of a health professional's responsibility to communicate all relevant information to other clinicians and organisations on the specific details of a patient's condition. The CHS Division will now re-inform all health care professionals about their professional responsibility regarding this issue via a system of email cascade. Specifically the message for compliance with NMC Standards for Medicines Management will be given. Ensuring the message is conveyed will be achieved by cascading the information via their communications lead using direct emails to staff, the inclusion of key learning points of the case within the monthly briefing paper, and dissemination through the professional nurses monthly meeting by the lead nurses for physical and mental health.”

    Source location

    2013-0201-Response-by-Leicestershire-Partnership-NHS
    Page 2 · response
    Published 5 September 2013

    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

    Provide medicines-management and emotional-resilience training, monthly clinical supervision for six months, and reflective-practice assessment to strengthen the nurse’s clinical decision-making.

    Verbatim wording from the response

    “As a result of this process Nurse ████████ is judged to be competent in all areas of clinical practice assessed. However in response to the concerns raised a programme of training has now been arranged for Nurse ████████ which includes medicines management training and emotional resilience training. In addition she will participate in additional clinical supervision on a monthly basis for six months and undertake a reflective practice assessment, the sum of which is to strengthen her clinical decision making skills.”

    Source location

    2013-0201-Response-by-Leicestershire-Partnership-NHS
    Page 3 · response
    Published 5 September 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026