Recurring concern

Unreliable anticoagulation reversal decisions

First to latest report 23 Oct 2014 — 30 Mar 2026

Reports that mention this concern
4
Times this concern has been raised
5
Stated actions linked to this concern
3

What this concern includes

Includes failures in the dedicated process for deciding, authorising, communicating or initiating urgent reversal of anticoagulation, including unclear responsible specialties, unclear reversal criteria, inadequate guidance for patients with serious bleeding or intracerebral haemorrhage, and failure to communicate the applicable reversal protocol to relevant clinical staff.

What is not included
  • Excludes general anticoagulant prescribing, routine monitoring or thromboprophylaxis failures where urgent reversal decision-making is not the unsafe condition.
  • Excludes medication administration or supply failures after an appropriate anticoagulation-reversal decision has been made.
  • Excludes generic clinical training, communication or responsibility-allocation deficiencies unless they directly concern urgent anticoagulation reversal decisions.
  • Excludes availability or licensing of a specific reversal agent where the deficiency is not the decision process for determining and initiating reversal.

Reports and published responses 4 reports

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

  1. Berkshire

    AI-generated summary

    John Albert TARRANT · 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

    John Albert Tarrant, aged 84, died at Wexham Park Hospital after an unwitnessed fall while an inpatient on 29 April 2025, sustaining a brain bleed that later became unsurvivable. The principal concerns were inaccurate falls risk assessments and insufficient awareness or prompting regarding the urgency of anticoagulation reversal after a fall.

    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

    Poor understanding of anticoagulation risks and reversal urgency

    Wider context from the report

    “2. Anti coagulation risk awareness The doctor who reviewed the CT results and neurosurgery advice after Mr Tarrant fell did not appreciate the urgency of the situation. I found in this inquest that due to timing issues this was not likely to have affected the outcome for Mr Tarrant. I heard from the consultant witness that the risks of anticoagulation are poorly understood. The post falls proforma was reviewed in court and, whilst it asked whether the patient was on anticoagulation medication, it did not provide a prompt about this during the post fall medical planning section. This led to a concern that the importance of considering and administering an anticoagulation reversal medication and the urgency of such a need may be underappreciated. ”

    Source location

    John Albert TARRANT · 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

    Failure of the post-falls proforma to prompt consideration of anticoagulation reversal and urgency

    Wider context from the report

    “2. Anti coagulation risk awareness The doctor who reviewed the CT results and neurosurgery advice after Mr Tarrant fell did not appreciate the urgency of the situation. I found in this inquest that due to timing issues this was not likely to have affected the outcome for Mr Tarrant. I heard from the consultant witness that the risks of anticoagulation are poorly understood. The post falls proforma was reviewed in court and, whilst it asked whether the patient was on anticoagulation medication, it did not provide a prompt about this during the post fall medical planning section. This led to a concern that the importance of considering and administering an anticoagulation reversal medication and the urgency of such a need may be underappreciated. ”

    Source location

    John Albert TARRANT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Nottinghamshire

    AI-generated summary

    Ruth Diane Eggleton · 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

    Ruth Diane Eggleton fell in her garden on 2 April 2023 and sustained a head injury with a small subdural haemorrhage. She was taking Rivaroxaban, which was not withheld or reversed, and she was discharged from hospital; the report identified concerns about the lack of an evidence-based protocol for managing DOAC anticoagulation.

    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 an evidence-based protocol for withholding or reversing DOAC and prescribing alternative anticoagulant medication

    Wider context from the report

    “1. There is a lack of evidence-based protocol for determining when to withhold and/or reverse DOAC, and when to prescribe alternative anticoagulant medication. I heard evidence from clinicians that the lack of such a protocol has led to divergence of practice amongst clinicians. I am not reassured that necessary actions to address the serious issue identified are in place. ”

    Source location

    Ruth Diane Eggleton · 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

    Continue monitoring new evidence on DOAC anticoagulation decisions.

    Verbatim wording from the response

    “NICE will continue to monitor new evidence in this area of practice, and will develop or update our guidance accordingly.”

    Source location

    Response from NICE
    Page 2 · response
    Published 4 July 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

    Develop or update NICE guidance on DOAC anticoagulation decisions in response to new evidence.

    Verbatim wording from the response

    “NICE will continue to monitor new evidence in this area of practice, and will develop or update our guidance accordingly.”

    Source location

    Response from NICE
    Page 2 · response
    Published 4 July 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

    NICE cannot develop useful guidance on DOAC reversal decisions because high-quality evidence is lacking and decisions require individual clinical judgement.

    Verbatim wording from the response

    “We agree that consideration should be given to reversing and withholding anticoagulation when a person prescribed these medications experiences significant bleeding. The reason for anticoagulation (which is not mentioned in your report) must be balanced against the estimated risk of further bleeding. In rare cases, alternative anticoagulation may be considered. Unfortunately, there is very little research evidence on which guidelines relevant to this complex decision could be based, and a high degree of clinical judgement is required in each case.”

    Source location

    Response from NICE
    Page 1 · response
    Published 4 July 2024

    Open published response

  3. Portsmouth and South East Hampshire

    AI-generated summary

    Michael Blow · 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

    Michael Blow was admitted after falling downstairs and sustained chest injuries, including fractured ribs, lung contusions and a pneumothorax. His condition later deteriorated, with blood in the chest drain, an INR of 9, and he died following cardiac arrest; the recorded cause of death included haemothorax, fractured ribs and warfarin treatment. Concerns included a requested INR test not being carried out and warfarin being restarted using an outdated INR result without sufficient account of other treatments and medication.

    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 clarity about when to reverse the anticoagulation protocol

    Wider context from the report

    “3. The clinical evidence heard at the inquest suggests that there is a need to highlight the relevant protocol to junior doctors and nurse practitioners and clarify when to reverse the protocol; who is responsible for this sort of clinical decision; and, importantly when to restart normal warfarin treatment. ”

    Source location

    Michael Blow · 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

    Unclear responsibility for deciding when immediate reversal is needed

    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

    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

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

Back to top

Data last updated 7 September 2026