Recurring concern

Unsafe anticoagulant management

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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
Individual concerns: 34
Date range: 2013–2026
Stated actions: 28

Reports over time

Reports about this concern issued each year.

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

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

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.

10 Jun2015
North London
Concerns raised1
1. Failure to consider anticoagulant therapy
This report raised 2 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.
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
24 Apr2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Unreliable booking system for community INR testing
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
5 Feb2015
Black Country
Concerns raised1
1. Lack of clear policy or training for dealing with patients on anticoagulant therapy
This report raised 2 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.
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
23 Oct2014
Nottinghamshire
Concerns raised1
1. Absence of clear guidelines for managing patients with intra-cerebral bleeds while on Warfarin or similar medication
This report raised 2 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 3
1. Action
  Agree a guideline for prompt treatment of warfarin patients presenting with intracranial haemorrhage.
  Stated by Nottingham University Hospitals NHS TrustStated completed
2. Action
  Finalise a cross-specialty guideline clarifying anticoagulation reversal responsibility and enabling rapid intervention.
  Stated by Nottingham University Hospitals NHS TrustStated in progress
3. Action
  Share the agreed guideline with relevant medical staff and add it to the NUH guideline app.
  Stated by Nottingham University Hospitals NHS TrustStated planned
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 Sep2013
Leicester City and South Leicestershire
Concerns raised1
1. Failure to seek medical advice before administering anticoagulants despite known bleeding
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 2
1. Action
  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.
  Stated by Leicestershire Partnership NHS TrustStated planned
2. Action
  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.
  Stated by Leicestershire Partnership NHS TrustStated planned
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to consider anticoagulant therapy

Concerns raised1

Unreliable booking system for community INR testing

Concerns raised1

Lack of clear policy or training for dealing with patients on anticoagulant therapy

Concerns raised1

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

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.3

Concerns raised1

Failure to seek medical advice before administering anticoagulants despite known bleeding

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

Actions described in response 3

Actions described in response 2