Recipient

Glenroyd Medical Centre

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First report 27 Jun 2019•Latest report 27 Jun 2019

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
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 Glenroyd Medical Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Blackpool and the Fylde

    AI-generated summary

    Frank Raymond STOCKTON · 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

    Frank Raymond Stockton was admitted to hospital with shortness of breath and collapse, later experienced recurrent nosebleeds while receiving oxygen therapy and Warfarin, and died on 22 July 2018 after developing melena and haematemesis. The principal concern was that the risks of epistaxis causing or contributing to death, particularly in patients receiving oxygen therapy or Warfarin or with impaired lung or heart function, may not be generally recognised by clinicians, and that maintaining the INR within its target range may not prevent this risk.

    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 Glenroyd Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clinician awareness that maintaining a target Internationalised Normalised Ratio does not eliminate the risk of death

    Wider context from the report

    “(1) It was the evidence of a number of clinicians who gave evidence in the course of the inquest that they had not come across a death occasioned by epistaxis in the course of their clinical careers. In those circumstances the cause of the deceased’s death may have been unusual. In that regard he received oxygen therapy both in hospital and, following discharge, at home through a nasal cannula and was also prescribed Warfarin on account of his atrial fibrillation. Whilst, for much of the period in question his Internationalised Normalised Ratio fell within the target range of 2.0 – 3.0 he developed epistaxis which, in the context of and in combination with compromised lung and heart function due to pulmonary fibrosis and ischaemic heart disease, caused his death. In the course of preparing statements for the purpose of the inquest 2 practitioners did not identify and/or did not identify the significance of 2 references to nosebleeds (epistaxis) (or the possibility thereof) within the clinical records. Thus the concern arises that (1) the risks of epistaxis causing or contributing to death, particularly in a patient who is receiving oxygen therapy and/or who is taking Warfarin and/or who has underlying conditions which impair lung and/or heart function and (2) the fact that the risk of death may not be avoided merely on account of the maintenance of a patient’s Internationalised Normalised Ratio within a target range may not be known generally amongst clinicians such that circumstances creating a risk of other deaths will occur or will continue to exist in the future. ”
    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 Glenroyd Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clinician awareness of the fatal risks of epistaxis in patients receiving oxygen therapy, taking Warfarin, or with impaired lung or heart function

    Wider context from the report

    “(1) It was the evidence of a number of clinicians who gave evidence in the course of the inquest that they had not come across a death occasioned by epistaxis in the course of their clinical careers. In those circumstances the cause of the deceased’s death may have been unusual. In that regard he received oxygen therapy both in hospital and, following discharge, at home through a nasal cannula and was also prescribed Warfarin on account of his atrial fibrillation. Whilst, for much of the period in question his Internationalised Normalised Ratio fell within the target range of 2.0 – 3.0 he developed epistaxis which, in the context of and in combination with compromised lung and heart function due to pulmonary fibrosis and ischaemic heart disease, caused his death. In the course of preparing statements for the purpose of the inquest 2 practitioners did not identify and/or did not identify the significance of 2 references to nosebleeds (epistaxis) (or the possibility thereof) within the clinical records. Thus the concern arises that (1) the risks of epistaxis causing or contributing to death, particularly in a patient who is receiving oxygen therapy and/or who is taking Warfarin and/or who has underlying conditions which impair lung and/or heart function and (2) the fact that the risk of death may not be avoided merely on account of the maintenance of a patient’s Internationalised Normalised Ratio within a target range may not be known generally amongst clinicians such that circumstances creating a risk of other deaths will occur or will continue to exist in the future. ”
    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 Glenroyd Medical Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify the significance of references to nosebleeds in clinical records

    Wider context from the report

    “(1) It was the evidence of a number of clinicians who gave evidence in the course of the inquest that they had not come across a death occasioned by epistaxis in the course of their clinical careers. In those circumstances the cause of the deceased’s death may have been unusual. In that regard he received oxygen therapy both in hospital and, following discharge, at home through a nasal cannula and was also prescribed Warfarin on account of his atrial fibrillation. Whilst, for much of the period in question his Internationalised Normalised Ratio fell within the target range of 2.0 – 3.0 he developed epistaxis which, in the context of and in combination with compromised lung and heart function due to pulmonary fibrosis and ischaemic heart disease, caused his death. In the course of preparing statements for the purpose of the inquest 2 practitioners did not identify and/or did not identify the significance of 2 references to nosebleeds (epistaxis) (or the possibility thereof) within the clinical records. Thus the concern arises that (1) the risks of epistaxis causing or contributing to death, particularly in a patient who is receiving oxygen therapy and/or who is taking Warfarin and/or who has underlying conditions which impair lung and/or heart function and (2) the fact that the risk of death may not be avoided merely on account of the maintenance of a patient’s Internationalised Normalised Ratio within a target range may not be known generally amongst clinicians such that circumstances creating a risk of other deaths will occur or will continue to exist in the future. ”
    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