Recipient

Warwick Hospital

First report 19 Dec 2019•Latest report 7 May 2024

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: 4
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 Warwick Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

7 May2024
Warwickshire
Concerns raised5
1. Failure to specify and disseminate learning from the DOAC pausing incident
2. Failure to coordinate pericardiocentesis timing with the duration of DOAC interruption
3. Lack of clear guidance for clinicians on pausing DOACs
1. Failure to communicate, recognise and act on time-critical DOAC directions
2. Inconsistent understanding and application of DOAC pausing decisions
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

David RILEY · 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

David Riley developed a pericardial effusion after atrial fibrillation ablation and later suffered a stroke before dying on 10 June 2023. Concerns included inconsistent decisions about pausing Apixaban, delays in restarting it, inadequate communication and continuity of care, and difficulties using computerised clinical records.

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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to specify and disseminate learning from the DOAC pausing incident
Wider context from the report
“Although the Warwick hospital conducted a Root Cause Analysis Investigation Report (RCAIR) of 6 July 2023 which indicated that the pausing of the DOAC was a lesson learned, it did not indicate what was learned. The only further action was limited to the incident being presented at the Grand Round, but this had not taken place at the time of the inquest, some 9 months after publication of the RCAIR. There are remaining outstanding matters of concern. ”
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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to coordinate pericardiocentesis timing with the duration of DOAC interruption
Wider context from the report
“2. Effective communication From the evidence, there was a failure to effectively communicate, recognise and act on directions that were time critical, such as restarting the DOAC as directed. It does not appear that there was any consideration as to the timing of the pericardiocentesis to ensure that the DOAC was paused for a short a time as possible. The evidence suggested that this may be due to lack of continuity of care and the difficulties in the way in which computerised clinical/pharmacy records are updated and accessed. Clear communication between medical staff is essential to patient care. ”
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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear guidance for clinicians on pausing DOACs
Wider context from the report
“1. Decisions regarding pausing of DOACs. It was not clear if there is national guidance available to clinicians regarding the pausing of DOACs and the considerations to be applied in making that decision. If there is such guidance, it is not widely understood or on the evidence given, followed consistently from hospital to hospital or within different teams. The inconsistency of approach appears from the evidence to increase the risk of misunderstanding and to put patients with atrial fibrillation at risk. ”
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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate, recognise and act on time-critical DOAC directions
Wider context from the report
“2. Effective communication From the evidence, there was a failure to effectively communicate, recognise and act on directions that were time critical, such as restarting the DOAC as directed. It does not appear that there was any consideration as to the timing of the pericardiocentesis to ensure that the DOAC was paused for a short a time as possible. The evidence suggested that this may be due to lack of continuity of care and the difficulties in the way in which computerised clinical/pharmacy records are updated and accessed. Clear communication between medical staff is essential to patient care. ”
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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent understanding and application of DOAC pausing decisions
Wider context from the report
“1. Decisions regarding pausing of DOACs. It was not clear if there is national guidance available to clinicians regarding the pausing of DOACs and the considerations to be applied in making that decision. If there is such guidance, it is not widely understood or on the evidence given, followed consistently from hospital to hospital or within different teams. The inconsistency of approach appears from the evidence to increase the risk of misunderstanding and to put patients with atrial fibrillation at risk. ”
Open source report
15 Oct2021
Warwickshire
Concerns raised3
1. Failure of the discharge process
2. Failure to act on significant hypothyroidism identified by thyroid blood tests
3. Failure to flag significant hypothyroidism on thyroid blood tests
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 Harbans SINGH · 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 Singh was admitted to Warwick Hospital with severe hypothyroidism on 23 April 2021 and died the following day. Concerns included failures in the discharge process, omission of his new diagnosis and medication from the discharge summary, and significant thyroid blood-test results not being flagged or acted upon.

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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of the discharge process
Wider context from the report
“i. During the inquest it was accepted there was a system failure regarding the discharge process and I am concerned that such a situation will not re-occur. ”
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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to act on significant hypothyroidism identified by thyroid blood tests
Wider context from the report
“ii. I am concerned that the thyroid blood tests in August 2020 and April 2121 (described as demonstrating significant hypothyroidism) were seemingly not flagged nor acted upon. ”
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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to flag significant hypothyroidism on thyroid blood tests
Wider context from the report
“ii. I am concerned that the thyroid blood tests in August 2020 and April 2121 (described as demonstrating significant hypothyroidism) were seemingly not flagged nor acted upon. ”
Open source report
26 Nov2020
Warwickshire
Concerns raised3
1. Failure to act on written instruction to treat as suspected subarachnoid haemorrhage unless excluded by CT scan
2. Inability of the GP team to access the electronic record
3. Delays in scanning clinical notes onto the electronic system
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

Eleanor Emily SHERMAN · 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

Eleanor Emily SHERMAN died at Warwick Hospital on 20 August 2020 after collapsing at home; a CT scan confirmed a subarachnoid haemorrhage. The report identified two misdiagnoses, failure to read the GP referral letter, and systemic problems with access to the GP’s electronic records and the scanning of notes.

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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to act on written instruction to treat as suspected subarachnoid haemorrhage unless excluded by CT scan
Wider context from the report
“(1) Two misdiagnoses at Warwick Hospital notwithstanding the GP specifically stating in writing that Mrs Sherman should be treated as a SAH unless a CT scan showed to the contrary (2) Systemic errors regarding the inability of the GP team at Warwick Hospital to access the electronic record and the slowness of notes being scanned on to the system. ”
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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inability of the GP team to access the electronic record
Wider context from the report
“(1) Two misdiagnoses at Warwick Hospital notwithstanding the GP specifically stating in writing that Mrs Sherman should be treated as a SAH unless a CT scan showed to the contrary (2) Systemic errors regarding the inability of the GP team at Warwick Hospital to access the electronic record and the slowness of notes being scanned on to the system. ”
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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in scanning clinical notes onto the electronic system
Wider context from the report
“(1) Two misdiagnoses at Warwick Hospital notwithstanding the GP specifically stating in writing that Mrs Sherman should be treated as a SAH unless a CT scan showed to the contrary (2) Systemic errors regarding the inability of the GP team at Warwick Hospital to access the electronic record and the slowness of notes being scanned on to the system. ”
Open source report
19 Dec2019
Warwickshire
Concerns raised1
1. Failure to correctly place nasogastric tubes
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

Colin Beaumont · 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

Colin Beaumont was the subject of an investigation into his death, which concluded at an inquest resulting in a Narrative Verdict. The report raised concern that a nasogastric tube was misplaced twice, leading to a pneumothorax that directly contributed to his death.

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 Warwick Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to correctly place nasogastric tubes
Wider context from the report
“(1) the fact that a Naso Gastric tube was misplaced twice in the same patient leading to a pneumothorax which directly contributed to death ”
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 raised5

Failure to specify and disseminate learning from the DOAC pausing incident

Failure to coordinate pericardiocentesis timing with the duration of DOAC interruption

Lack of clear guidance for clinicians on pausing DOACs

Failure to communicate, recognise and act on time-critical DOAC directions

Inconsistent understanding and application of DOAC pausing decisions

Concerns raised3

Failure of the discharge process

Failure to act on significant hypothyroidism identified by thyroid blood tests

Failure to flag significant hypothyroidism on thyroid blood tests

Concerns raised3

Failure to act on written instruction to treat as suspected subarachnoid haemorrhage unless excluded by CT scan

Inability of the GP team to access the electronic record

Delays in scanning clinical notes onto the electronic system

Concerns raised1

Failure to correctly place nasogastric tubes