North Caerphilly Community Mental Health Team

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First report 9 Jul 2015•Latest report 9 Jul 2015

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from North Caerphilly Community Mental Health Team 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

    Mr. Alun Walters · 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. Alun Walters, who was prescribed Warfarin following receipt of a metallic heart valve, died after a gastro-intestinal haemorrhage in circumstances of suspected elevated Warfarin levels and failed INR monitoring. His prescriptions continued despite no INR tests after November 2013, and 51 prescriptions were provided without dosage assessment. Concerns included failures by the medical practice in monitoring, prescription systems and notifying the pharmacy that Warfarin had been withdrawn, while the pharmacy supplied Warfarin without a valid prescription.

    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 North Caerphilly Community Mental Health Team; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing

    Wider context from the report

    “The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
    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 North Caerphilly Community Mental Health Team; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to develop and maintain an anti-coagulation treatment register

    Wider context from the report

    “The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
    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 North Caerphilly Community Mental Health Team; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to use computer software to support prescription decisions

    Wider context from the report

    “The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
    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 North Caerphilly Community Mental Health Team; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement notification of failed attendance for INR testing

    Wider context from the report

    “The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
    Open source report
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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