Alun Walters
PFD Report
Historic (No Identified Response)
Ref: 2015-0262
Coroner's Concerns (AI summary)
The medical practice failed to use computer software for prescription decisions, breached its anti-coagulation register contract, and lacked systems for notifying GPs of missed INR tests or Warfarin withdrawal.
View full coroner's concerns
The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing.
Sent To
- Aneurin Bevan University Health Board
- Cwm Taf University Health Board
- National Assembly for Wales
- North Community Mental Health Team
- Lawn Medical Practice
Response Status
Linked responses
0 of 5
56-Day Deadline
3 Sep 2015
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 27th March, 2015 I commenced an investigation into the death of Mr. Alun Walters. The investigation concluded at the end of the inquest on the 26th
June, 2015. The conclusion of the inquest was ‘A gastro-intestinal haemorrhage in the circumstance of suspected elevated levels of Warfarin and failed INR monitoring’.
June, 2015. The conclusion of the inquest was ‘A gastro-intestinal haemorrhage in the circumstance of suspected elevated levels of Warfarin and failed INR monitoring’.
Circumstances of the Death
Mr. Alun Walters had longstanding mental health difficulties and alcohol misuse for which he was receiving community psychiatric support. He had been prescribed Warfarin as an anticoagulation therapy since 2011 following the receipt of a metallic heart valve. Mr. Walters was aware of the need for regular INR testing. He joined the Lawn Medical Practice in 2012 and received weekly Warfarin prescriptions from the Practice. The Practice was contracted by the Aneurin Bevan University Health Board to provide INR testing, dosing and prescriptions. Regular INR tests were undertaken until November 2013. In December 2013 Mr. Walters failed to attend for his routine INR test which triggered contact by the Practice advising him to continue his INR testing. No further tests were actually undertaken by the Practice although his prescriptions continued.
In January, 2015 , the Practice’s Health Care Assistance, happened to see Mr. Walters in town. She noted that she had an INR test at the Practice since November 2013 and immediately alerted GP. In consequence, Mr. Walters was contacted by on 30 January, 2015 advising that he urgently needed to attend for INR testing or GP consultation. On 29th Pharmacist, of the Rhymney Pharmacy Ltd. noted that Warfarin, a longstanding prescription for Mr. Walters, had been dropped from Mr. Walter’s prescription list. Believing this to be an error, he continued to provide it. The GP Practice had not notified the Pharmacy that Mr. Walter’s longstanding prescription of Warfarin had been discontinued. Both at Inquest and during interview with the Aneurin Bevan University Health Board’s Pharmacy Advisors, admitted that Warfarin was supplied to Mr. Walters in February to April, 2015 without a valid prescription.
confirmed at Inquest that he was not aware of the National Patient Safety Agency’s Safety Alert No. 18 entitled ‘Actions than can make Anticoagulation Therapy Safer’ dated 27.03.07 which states - January, 2015 the GP Practice’s computer prescription data base for Mr. Walters noted that Warfarin was discontinued. A total of 51 prescriptions had been provided to Mr. Walters without the benefit of dosage assessment following INR testing. ‘Ensure that before dispensing a repeat prescription for anti-coagulation medication, they check that the patient’s INR is being monitored regularly and that it is at a safe level for the repeat prescription to be dispensed’.
In January, 2015 , the Practice’s Health Care Assistance, happened to see Mr. Walters in town. She noted that she had an INR test at the Practice since November 2013 and immediately alerted GP. In consequence, Mr. Walters was contacted by on 30 January, 2015 advising that he urgently needed to attend for INR testing or GP consultation. On 29th Pharmacist, of the Rhymney Pharmacy Ltd. noted that Warfarin, a longstanding prescription for Mr. Walters, had been dropped from Mr. Walter’s prescription list. Believing this to be an error, he continued to provide it. The GP Practice had not notified the Pharmacy that Mr. Walter’s longstanding prescription of Warfarin had been discontinued. Both at Inquest and during interview with the Aneurin Bevan University Health Board’s Pharmacy Advisors, admitted that Warfarin was supplied to Mr. Walters in February to April, 2015 without a valid prescription.
confirmed at Inquest that he was not aware of the National Patient Safety Agency’s Safety Alert No. 18 entitled ‘Actions than can make Anticoagulation Therapy Safer’ dated 27.03.07 which states - January, 2015 the GP Practice’s computer prescription data base for Mr. Walters noted that Warfarin was discontinued. A total of 51 prescriptions had been provided to Mr. Walters without the benefit of dosage assessment following INR testing. ‘Ensure that before dispensing a repeat prescription for anti-coagulation medication, they check that the patient’s INR is being monitored regularly and that it is at a safe level for the repeat prescription to be dispensed’.
Action Should Be Taken
in the area of:
Ensuring pathways of communication are in place in respect of a patient’s anticoagulation dosing, INR testing, failed attendance for INR testing and changes of prescription both within the GP Practice and to external agencies including pharmacies providing anti-coagulation prescriptions; and
ensuring the GP Practice is compliant with its responsibilities of maintaining a register of patient anticoagulation dosing and testing.
Ensuring pathways of communication are in place in respect of a patient’s anticoagulation dosing, INR testing, failed attendance for INR testing and changes of prescription both within the GP Practice and to external agencies including pharmacies providing anti-coagulation prescriptions; and
ensuring the GP Practice is compliant with its responsibilities of maintaining a register of patient anticoagulation dosing and testing.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.