Recipient

Bryntirion Surgery

First report 27 Jul 2015•Latest report 4 Sep 2015

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Bryntirion Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

4 Sep2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Inadequate monitoring of INR levels
2. Inadequate communication about anticoagulation monitoring and potential therapy adjustment
3. Lack of certainty whether Warfarin was being taken
1. Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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 Bryntirion Surgery; 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 Bryntirion Surgery; 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 Bryntirion Surgery; 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 Bryntirion Surgery; 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
27 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised4
1. Insufficient staffing of Tissue Viability Nurses
2. Failure to maintain adequate repositioning charts
3. Failure to maintain adequate pressure ulcer documentation
1. Lack of integrated skin care across Health Boards and Primary healthcare services
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mr. Arthur Cook · 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

Mr. Arthur Cook had poor circulation and a chronic open wound that developed into an MRSA-infected category 4 pressure ulcer while he was resident at Four Seasons Healthcare Residential Home. He failed to respond to treatment and died. Concerns included insufficient tissue viability nursing capacity, inadequate pressure-ulcer documentation and repositioning charts, and a lack of integrated skin care across services.

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 Bryntirion Surgery; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing of Tissue Viability Nurses
Wider context from the report
“(1) Staffing levels of Tissue Viability Nurses within the Aneurin Bevan Health Board are low and to the extent that at times this service cannot be provided according to need; ”
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 Bryntirion Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain adequate repositioning charts
Wider context from the report
“(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
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 Bryntirion Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain adequate pressure ulcer documentation
Wider context from the report
“(2) The CTUHB and residential Care Home failed to maintain adequately pressure ulcer documentation and repositioning charts making more likely the progression of MRSA infected pressure ulcers and wounds failing to heal. ”
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 Bryntirion Surgery; that does not assign responsibility.
PFD Monitor interpretation
Lack of integrated skin care across Health Boards and Primary healthcare services
Wider context from the report
“(3) An apparent lack of integrated skin care within and between Health Boards and Primary healthcare services. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised4

Inadequate monitoring of INR levels

Inadequate communication about anticoagulation monitoring and potential therapy adjustment

Lack of certainty whether Warfarin was being taken

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

Concerns raised4

Insufficient staffing of Tissue Viability Nurses

Failure to maintain adequate repositioning charts

Failure to maintain adequate pressure ulcer documentation

Lack of integrated skin care across Health Boards and Primary healthcare services