“Inadequate monitoring of INR levels in a patient suffering from dementia; (2) Lack of…”
Dated 4 Sep 2015, from the coroner for Powys. Sent to 6 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Dates unclearOrganisations 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; a reply may have been sent and not yet published.
The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due.
- Report dated4 Sep 2015
- Published on judiciary.uk4 Aug 2015
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Responses from each recipient
| Sent to | Response |
|---|---|
| National Assembly for Wales | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
| Cwm Taf Morgannwg University Health Board | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
| Aneurin Bevan University Health Board | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
| Care Inspectorate Wales | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
| REDACTED | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
| Brindaavan Care Home Limited | Dates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due. |
The coroner’s concerns
(1) Inadequate monitoring of INR levels in a patient suffering from dementia; (2) Lack of certainty whether Warfarin was being taken by the patient; (3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment; and (4) That against this background and the Care Home’s concern about a possible ischaemic leg, Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy.
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
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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