“as follows:- (1) The practices and procedures implemented by the Practice 1, Keir Hardie…”
Dated 11 Sep 2015, from the coroner for Powys. Sent to 4 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
Deadline passedReplies were due by 6 Nov 2015. 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 dated11 Sep 2015
- Deadline6 Nov 2015
- Published on judiciary.uk11 Sep 2015
- Today21 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| National Assembly for Wales | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Nov 2015. A reply may have been sent and not yet published. |
| Cwm Taf Morgannwg University Health Board | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Nov 2015. A reply may have been sent and not yet published. |
| Practice 1 Keir Hardie Health Park | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Nov 2015. A reply may have been sent and not yet published. |
| REDACTED | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 6 Nov 2015. 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.
as follows:- (1) The practices and procedures implemented by the Practice 1, Keir Hardie Health Park, GP Surgery following Mr Bonfield’s death (with regard to monitoring the compliance of the Health Boards District Nurse Teams following delegation to undertake a patient's INR testing) is not uniform and/or implemented across all of the Health Boards Level 4 Accredited GP practices. (2) The practices and procedures implemented by Practice 1, Keir Hardie Health Park Surgery act as a check and balance to reduce the risk of an unmonitored/unactioned failure on the part of the District Nurse service to undertake the task(testing the patients INR level) delegated to them by the GP practice concerned. (3) Until such action is taken there remains a risk that a future death(s) could occur in similar circumstances to Mr Bonfield’s, where delegated INR testing has not been done leading to un-monitored over anti-coagulation
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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