Recurring concern

Unreliable anticoagulation reversal decisions

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First reported 23 Oct 2014•Latest report 30 Mar 2026

Definition

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.

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: 4
Individual concerns: 5
Date range: 2014–2026
Stated actions: 3

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.

Frimley Health NHS Foundation Trust1

National Institute for Health and Care Excellence1

Nottingham University Hospitals NHS Trust1

Portsmouth Hospitals University NHS 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.

30 Mar2026
Berkshire
Concerns raised2
1. Poor understanding of anticoagulation risks and reversal urgency
2. Failure of the post-falls proforma to prompt consideration of anticoagulation reversal and urgency
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

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
3 Jul2024
Nottinghamshire
Concerns raised1
1. 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 2
1. Action
  Continue monitoring new evidence on DOAC anticoagulation decisions.
  Stated by National Institute for Health and Care ExcellenceStated in progress
2. Action
  Develop or update NICE guidance on DOAC anticoagulation decisions in response to new evidence.
  Stated by National Institute for Health and Care ExcellenceStated planned
Respondent positions 1
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 act
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
12 Aug2016
Portsmouth and South East Hampshire
Concerns raised1
1. Lack of clarity about when to reverse the anticoagulation protocol
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.
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
23 Oct2014
Nottinghamshire
Concerns raised1
1. Unclear responsibility for deciding when immediate reversal is needed
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 1
1. Action
  Finalise a cross-specialty guideline clarifying anticoagulation reversal responsibility and enabling rapid intervention.
  Stated by Nottingham University Hospitals NHS TrustStated in progress
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Poor understanding of anticoagulation risks and reversal urgency

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

Concerns raised1

Lack of an evidence-based protocol for withholding or reversing DOAC and prescribing alternative anticoagulant 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.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of clarity about when to reverse the anticoagulation protocol

Concerns raised1

Unclear responsibility for deciding when immediate reversal is needed

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

Actions described in response 2

Respondent positions 1

Actions described in response 1