PFD report

David Wade · Prevention of Future Deaths report

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Issued 6 Sep 2016•Blackburn, Hyndburn and Ribble Valley

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised2

  1. Lack of literature informing anticoagulant therapy patients about the steps to take in response to a brain bleed
    Part of recurring concern: Unsafe management of significant bleeding
  2. Lack of literature informing anticoagulant therapy patients about the symptoms of a brain bleed
    Part of recurring concern: Unsafe anticoagulant management
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing anticoagulant information, including the Yellow OAT book, NHS Choices guidance and NICE support, addresses patients’ need for bleeding-symptom advice.

    Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of literature informing anticoagulant therapy patients about the steps to take in response to a brain bleed

Wider context from the report

“Patients who are provided with anti-coagulant therapy are at an increased risk of the development of haemorrhagic strokes. There appears to be no system in place to provide patients with literature setting out the symptoms of a bleed on the brain and the steps that patients should take in response. ”

Is this part of a recurring concern?

Yes — Unsafe management of significant bleeding.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of literature informing anticoagulant therapy patients about the symptoms of a brain bleed

Wider context from the report

“Patients who are provided with anti-coagulant therapy are at an increased risk of the development of haemorrhagic strokes. There appears to be no system in place to provide patients with literature setting out the symptoms of a bleed on the brain and the steps that patients should take in response. ”

Is this part of a recurring concern?

Yes — Unsafe anticoagulant management.

Open source report

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing anticoagulant information, including the Yellow OAT book, NHS Choices guidance and NICE support, addresses patients’ need for bleeding-symptom advice.

Verbatim wording from the response

“In light of your concerns I would wish to bring to your attention the standard anticoagulant booklet (more commonly known as the “yellow book” – which is warfarin specific) given to patients as recommended by the former National Patient Safety Agency. A link to its content is below: http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61777”

Source location

david-wade-Response
Page 1 · response
Published 6 September 2016

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026