Recipient name withheld

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First report 20 Nov 2023•Latest report 20 Nov 2023

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 Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Hertfordshire

    AI-generated summary

    Susan Ann GLADSTONE · 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

    Susan Ann Gladstone was admitted to Lister Hospital with pyelonephritis and an extremely elevated INR after taking warfarin and recently prescribed tramadol. She died on 8 January 2021; the principal concern was a potentially fatal interaction between tramadol and warfarin that caused exceptional thinning of her blood and brain bleeding.

    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of warnings to prescribing doctors about tramadol-warfarin interactions

    Wider context from the report

    “(3) A comment from the Anticoagulation Service in relation to tramadol reads "Known interactor although this is not listed in the BNF, from experience we have seen that this can increase the INR." There was nothing to warn the prescribing doctor of any possible interaction.(4) I found on the balance of probabilities that an interaction between tramadol and warfarin had caused this dangerous, and in the event fatal, INR level to develop. ”
    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