Recipient

Brindavan Care Home Limited

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First report 4 Sep 2015•Latest report 4 Sep 2015

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Brindavan Care Home Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mrs. Mary Patricia James · 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. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.

    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 Brindavan Care Home Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate monitoring of INR levels

    Wider context from the report

    “(1) Inadequate monitoring of INR levels in a patient suffering from dementia; ”
    Open source report

    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 Brindavan Care Home Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate communication about anticoagulation monitoring and potential therapy adjustment

    Wider context from the report

    “(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment; ”
    Open source report

    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 Brindavan Care Home Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of certainty whether Warfarin was being taken

    Wider context from the report

    “(2) Lack of certainty whether Warfarin was being taken by the patient; ”
    Open source report

    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 Brindavan Care Home Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment

    Wider context from the report

    “(4) That against this background and the Care Home’s concern about a possible ischaemic leg, Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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