“The INR test requested py iii during the morning of Saturday 27th was never carried out…”
Dated 12 Aug 2016, from the coroner for Portsmouth and South East Hampshire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 7 Oct 2016. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated12 Aug 2016
- Deadline7 Oct 2016
- Published on judiciary.uk12 Aug 2016
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Portsmouth Hospitals University NHS TrustNamed in the report as “Portsmouth Hospitals NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 7 Oct 2016. A reply may have been sent and not yet published. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
- 1. The INR test requested py iii during the morning of Saturday 27th was never carried out despite this being a basic check to baseline Mr Blow’s INR levels and see what effect the Octaplex and blood transfusion plus any antibiotic treatment since admission may have had on his reading to inform further treatment. 2. Warfarin was restarted after i review but was based on an outdated INR reading of 5.5 taken on admission and no account was taken of the Octaplex and blood transiusion plus any other medication such as antibiotics. 3. The clinical evidence heard at the inquest suggests that there is a need to highlight the relevant protocol to junior doctors and nurse practitioners and clarify when to reverse the protocol; who is responsible for this sort of clinical decision; and, importantly when to restart normal warfarin treatment.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use