Recipient

Brace Street Health Centre

First report 30 Oct 2019•Latest report 30 Oct 2019

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Multi-service care provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 7

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Brace Street Health Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

30 Oct2019
Black Country
Concerns raised1
1. Failure to independently verify warfarin dosage before prescribing
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
  Assign the assistant practice manager to check Warfarin requests during the practice manager’s leave.
  Stated planned
2. Action
  Require Warfarin patients to present yellow books, record and verify INR results and doses, and confirm prescriptions before issuing them.
  Stated completed
3. Action
  Implement a written procedure for prescribing Warfarin, checking INR results, and changing doses.
  Stated completed
Respondent positions 1
1. Position
  Existing Warfarin prescribing, monitoring and auditing systems are considered robust and sufficient to prevent further recurrences.
  Existing arrangements considered sufficient
AI-generated summary

Mrs Annie Lloyd · 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 Annie Lloyd was taking warfarin and appears to have taken a higher-than-intended dose for around two weeks. She was found unconscious on 6 April 2019 with a large subdural haematoma and raised intracranial pressure, and died the same day. Concerns identified during the inquest included inadequate checking of her warfarin dosage and reliance on family members to confirm the required dose.

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. The report was sent to Brace Street Health Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to independently verify warfarin dosage before prescribing
Wider context from the report
“1. Evidence emerged during the inquest that there was an inadequate process in place for checking the patient’s warfarin level dosage. It appears that a “yellow book” confirming the dosage was being copied and the GP issued the prescription without checking this. 2. The GP practice claim to have placed reliance on the family to confirm the dosage required. ”
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
Assign the assistant practice manager to check Warfarin requests during the practice manager’s leave.

Verbatim wording from the response
“a) The assistant practice manager will check Warfarin requests when the practice manager is on leave.”

Source location
2019-0493-Response-by-Brace-Street-Health-Centre
Page 3 · response
Published 30 October 2019
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
Require Warfarin patients to present yellow books, record and verify INR results and doses, and confirm prescriptions before issuing them.

Verbatim wording from the response
“1. All of our patients (who take Warfarin) have been told that they must bring in their yellow Warfarin book every time they go to have their INR checked at the hospital. The Warfarin book will be scanned and then given to the practice manager who will code the latest INR. She will then enter on to their consultation the date the INR was taken, the result, what dose of medication they should be taking and when their next INR is due. She will then request the correct strength as per the yellow Warfarin book. The General Practitioner will also check the details before issuing the prescription.”

Source location
2019-0493-Response-by-Brace-Street-Health-Centre
Page 1 · response
Published 30 October 2019
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
Implement a written procedure for prescribing Warfarin, checking INR results, and changing doses.

Verbatim wording from the response
“3. The Practice now has a written Procedure for the process of prescribing Warfarin, checking INR results and altering doses. Please find this document attached.”

Source location
2019-0493-Response-by-Brace-Street-Health-Centre
Page 1 · response
Published 30 October 2019
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
Existing Warfarin prescribing, monitoring and auditing systems are considered robust and sufficient to prevent further recurrences.

Verbatim wording from the response
“The receptionist will photocopy and scan the yellow book immediately and then give it to the practice manager who will code the latest INR and check the correct dose. The GP will then check it again. Our pharmacist is doing a quarterly audit to make sure we are not missing any patients.”

Source location
2019-0493-Response-by-Brace-Street-Health-Centre
Page 3 · response
Published 30 October 2019
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Brace Street Health Centre

Reports, concerns and published responses

Reports over time

Report topics

Concerns and recipient responses

Concerns raised1

Failure to independently verify warfarin dosage before prescribing

Actions described in response 3

Respondent positions 1

Mrs Annie Lloyd · Prevention of Future Deaths report

Report summary

How this individual concern was interpreted

PFD Monitor interpretation

Wider context from the report

How this respondent action was interpreted

PFD Monitor interpretation

Verbatim wording from the response

Source location

How this respondent action was interpreted

PFD Monitor interpretation

Verbatim wording from the response

Source location

How this respondent action was interpreted

PFD Monitor interpretation

Verbatim wording from the response

Source location

How this respondent position was interpreted

PFD Monitor interpretation

Verbatim wording from the response

Source location

Published response patterns

Published responses found

How actions were described at the time

Types of action described in responses

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Reports, concerns and published responses

Reports over time

Concerns raised1

Failure to independently verify warfarin dosage before prescribing

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 3

Respondent positions 1