Brace Street Health Centre

Private and voluntary organisations · Multi-service care provider

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First report 30 Oct 2019•Latest report 30 Oct 2019

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
7

Described in responses

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.

  1. Black Country

    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
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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