“(brief summary of matters of concern) The evidence heard raised a concern about the safe…”

The coroner’s concerns

(brief summary of matters of concern) The evidence heard raised a concern about the safe prescribing of warfarin. When a doctor is asked by a nurse to dose the warfarin, the accepted practice is that the doctor relies on the nurse to give all relevant information and the doctor only checks the INR blood results from the laboratory. There is no requirement or expectation that the doctor looks at the patient’s medical records or seeks information about the patient. At the inquest evidence was heard that the nurse had not communicated all relevant information. Although in this case it did not have an adverse outcome, it was accepted that there was a risk that if a doctor does not have all relevant information, warfarin could be prescribed and administered and there could be a risk of death. Evidence was given that this lack of appropriate communication was believed to be unusual but it was accepted that it is not necessarily known how unusual because it would probably only become apparent in cases of an adverse outcome.

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, 2024-0347

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