Marian Day

King’s Mill Hospital 
Mansfield Road 
Sutton in Ashfield 
Nottinghamshire 
NG17 4JL 

Tel: 
Join today: www.sfh-tr.nhs.uk 

PRIVATE AND CONFIDENTIAL 

Dr Elizabeth Didcock, Assistant Coroner  
The Council House 
Old Market Square 
Nottingham 
NG1 2DT 

By email only – c/o 

Dear Madam, 

I  am  responding  to  your  Regulation  28  Report  to  Prevent  Future  Deaths,  issued 
following  the  inquest  touching  the  death  of  Mrs  Marian  Day.  You  raised  concern 
about  prescription  errors  that  led  to  Mrs  Day  receiving  two  doses  of  warfarin  on 
consecutive days despite there being a medical plan that it should be withheld. You 
were  concerned  that  a  similar  error  may  occur  again  in  part  due  to  the  number  of 
charts  involved  in  the  prescribing  and  dosing  of  warfarin.  In  order  to  address  your 
concerns  we  have  undertaken  a  multidisciplinary  (MDT)  review  of  our  warfarin 
process, prescription and supporting documentation to address these concerns.  

Members  of  the  MDT  are  the  Clinical  Director  of  Patient  Safety,  Assistant  Chief 
Pharmacist and Medication Safety Officer, the Trust venous thromboembolism lead, 
Internal  Medicine,  Chief 
Specialty  Registrar  Geriatric 
Registrar/Emergency  Medicine  Trainee,  Head  of  Sherwood  Forest  Hospitals 
Governance  and  the  Coagulation  Clinical  Nurse  Specialist  team.  Prior  to  this  MDT 
meeting, further investigation was undertaken into the specific circumstances that led 
to  each  of  the  two  doses  of  warfarin  being  prescribed.  This  is  further  explained 
below. 

and  General 

Current warfarin prescribing and dosing practice at SFH NHS FT 

The current practice at Sherwood Forest Hospitals NHS Foundation Trust (SFHFT) 
is that warfarin dosing is recorded on a yellow warfarin dosing chart, separate from 
the paper ‘Medication Prescription and Administration Record’ which also known as 
the  ‘main  chart’.  The  warfarin  chart  is  separate  from  the  main  chart  due  to  the 
complexity of dosing for warfarin which changes depending on the most recent blood 

Patient Experience Team                                                                                      
01623 672222                                                    
sfh-tr.pet@nhs.net 

We are proud to 
be a smoke-free 
site 

Chair 
Chief Executive 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                      
 
 
 
 
 
 
 anticoagulation  test  result;  previous  experience  demonstrates  doses  are  missed 
without  this  separate  chart;  and  the  fact  that  small  numbers  of  patients  are  on 
warfarin,  so  this  large  section  would  be  irrelevant  for  the  vast  majority  of 
patients. SFHT’s warfarin prescription chart is yellow in colour and allows co-located 
documentation  of  the  latest  blood  anticoagulation  results  (Prothrombin  Time 
International  Normalised  Ratio  -  INR)  which  guides  future  prescription  and  dosing. 
The chart also acts as an administration recorded and additional key patient related 
information e.g. such as dose prior to admission, dosing responsibility on discharge, 
target INR etc.  This method of prescribing warfarin is in accordance with widespread 
national practice when utilising conventional paper-based prescribing systems.  

The  Medicine  Policy  at  SFHFT  states  that  the  existence  of  the  separate  warfarin 
chart, along with any other additional charts, must be documented on the front of the 
main chart as an aide memoire and quick reference for those involved in the care of 
the  patient  to  highlight  that  additional  charts  are  in  existence  and  must  be  referred 
to.  The prescriber is also expected to cross reference the warfarin prescription in the 
anticoagulation  section  of  the  main  chart  as  the  warfarin  is  written  up  on  the  main 
chart  and  the  variable  daily  dose  is  prescribed  each  day  on  the  yellow  warfarin 
dosing chart. If warfarin were to be omitted then it is expected that the warfarin would 
be  crossed  off  on  the  yellow  warfarin  chart  and  a  coded  omission  reason 
documented  on  the  main  chart,  this  is  cross  referenced  to  the  “Record  of  actions 
taken after medicine non administration” form at the back of the main chart. This is 
evident for the omitted dose on the 16/11/2019 for this case. 

In  addition  warfarin  administration  traditionally  occurs  at  6pm  across  the  health 
service  for  both  inpatients  and  for  those  patients  taking  it  at  home.  For  inpatients 
within hospitals, dosing decisions are often made or chased around this time of the 
day. 

Further investigation into the circumstances of Mrs Day’s warfarin dosing 

To  obtain  further  understanding  of  the  prescribing  process  and  decision  making 
,  consultant  physician,  met  with  the  two 
specific  to  this  incident,  Dr 
doctors  who  dosed  and  prescribed  the  warfarin  for  Mrs  Day.    The  doctor  who 
prescribed Mrs Day’s warfarin on the 14th November 2019 was an on call doctor and 
not  part  of  the  team  looking  after  her  care  and  treatment.    Unfortunately  she  was 
unable  to  recall  any  aspect  of  Mrs  Day’s  care,  nor  why  the  warfarin  was  dosed 
despite the plan being to withhold it. 

The  doctor  who  prescribed  Mrs  Day’s  second  dose  of  warfarin  on  15th  November 
2019 was able to remember Mrs Day and the rationale behind her prescribing.  She 
recalled that she was aware that Mrs Day was being managed and investigated for a 
possible gastrointestinal bleed but on a risk benefit analysis  felt that the patient’s on-
going risk of developing a deep vein thrombosis and potential for a ischaemic stroke 
or  transient  ischaemic  attack,  outweighed  the  risk  of  omitting  anticoagulation.    As 

2

 
 
 
 part of this clinical risk assessment the doctor was clear that she had considered at 
that  time  she  made  the  decision  that  Mrs  Day  had  been  stable  since  admission. 
There  was  also  no  evidence  of  on-going  melaena  (passing  altered  blood)  and  her 
haemoglobin  level  and  vital  signs  were  stable.  Based  on  her  assessment  of  the 
clinical  picture  at  the  time,  the  doctor  made  a  conscious  decision  to  prescribe  the 
warfarin  but  in  an  attempt  to  mitigate  the  risk  of  haemorrhage,  deliberately 
prescribing  a  lower  warfarin  dose.  Disappointingly  this  decision  making  was  not 
documented within the medical records.  

MDT conclusions 

First dose 

On reflection, considering particularly the views of the two junior doctors who formed 
part of the MDT and are closely involved in warfarin dosing, it is concluded that the 
most  likely  reason  that  the  warfarin  was  dosed  against  advice  was  a  lack  of  easily 
accessible information about the plan to omit it.  Warfarin dosing is often undertaken 
by ward doctors, not from the team most familiar with the patient, as it relies on the 
availability of recent INR blood test results.  It is concluded that the key factor is to 
ensure  that  doctors  dosing  warfarin  have  the  up-to-date  plan  easily  available  to 
them. I set out below actions to put this into effect. 

Second dose 

The ward doctor on this occasion was familiar with Mrs Day.  Whilst she made her 
own assessment of the risks and benefits of dosing warfarin that day, her conclusion 
differed  from  the  current  plan,  and  does  not  withstand  analysis  given  that  the 
suspected  GI  bleed  had  not  been  ruled  out.    Any  change  to  the  plan  at  this  stage 
should  have  been  made  in  consultation  with  a  senior  doctor,  and  been  fully 
documented. 

Immediate further actions 

1.  Decisions  on  changes  to  existing  warfarin  plans  to  be  documented  on  the 
yellow dosing chart at the time they are made, as well as in the clinical record. 
This will ensure that all doctors dosing warfarin are aware of the current plan 
even if they are not part of the treating team. 

2.  Changes to existing warfarin plans to be made only following discussion with 

senior doctors, and fully documented. 

On-going work 

3.  Steps  to  facilitate  the  parent  medical  team  to  dose  warfarin  whenever 
possible.  Warfarin  has  traditionally  been  dosed  and  administered  around 
18.00  as  it  required  the  results  of  INR  blood  tests  taken  earlier  that  day. 

3 

 
 
 
 Advancement  of  laboratory  technology  including  electronic  results  makes 
most results available earlier in the day.  Dosing before the parent team finish 
their shift is ideal as they will know their patients’ needs.  To achieve this we 
are working towards: 

a.  an MDT approach and the role of the nursing staff in prompting parent 
team doctors to prescribe/dose, once  INR results are available, before 
leaving  the  ward.  This  has  been  discussed  at  the  November  Trust 
Ward  Leaders  meeting  and  individuals  identified  to  take  this  work 
forward. 

b.  We  are  exploring  the  use  of  the  electronic  Nervecentre  clinical 
information  system  used  on  the  wards  to  inform  ward  doctors  when 
INR results are available, so that they can dose the warfarin as early as 
possible. 

4.  Consideration  of  the  benefits  of  prompts  in  the  warfarin  documentation  with 
regard  to  the  risks  for  thrombosis  versus  the  risks  of  bleeding  to  aide 
prescribing  decision  making.    For  discussion  at  Medicine  Safety  Group 
December 2020 [Assistant Chief Pharmacist and Medication Safety Officer to 
Present] 

5.  Further Education and Awareness: 

  Ensure all staff are aware that both charts must be amended if withholding 
warfarin  doses:  Learning  Matters  sent  out  November  2020.  [i-care 
electronic communication issued] 

  Communication  programme  across 

the  Trust 

to  raise  awareness. 

December 2020. 

  Add  this  patient  story  into  training  for  juniors  to  highlight  the  potential 
outcome of  warfarin  prescribing  errors: Training  updated  November 2020 
for inclusion in August 2021 junior doctor induction and going forwards. 

  Add  this  patient  story  into  training  for  nurses  to  highlight  the  potential 

outcome of warfarin administration errors. 

6.  Pharmacy  to  audit  documentation  compliance  for  the  immediate  further 
actions  described  above.  December  2020  Assistant  Chief  Pharmacist  and 
Medication Safety Officer to Conduct 

Prescribing documentation  

Changes  to  the  existing  warfarin  prescribing  documentation  have  been  carefully 
considered.  The  multi-disciplinary  panel  verbally  risk  assessed  the  possibility  of 

4 

 
 
 
 changing  the  entire  process  by  altering  the  prescription  charts.  The  differing 
expertise  outlined  that  if  this  was  conducted  then  there  would  be  an  increased 
likelihood  in  prescribing  and  dosing  errors  affecting  patients.  Therefore  it  was 
concluded by this expert panel that this would be highly unlikely not to help prevent 
future  deaths.  In  addition  the  roll  out  of    EPMA  (electronic  prescribing)  at  SFHFT, 
which  includes  warfarin  prescribing,    is  expected  to  pilot  in  February  2021  and 
realistically  any  changes  to  paper  documentation  would  be  highly  unlikely  to 
complete Trust governance processes and printing before this time. 

I hope I have been able to describe the seriousness that we have taken matter and 
demonstrated  a  real  commitment  to  improving  warfarin  dosing  safety  at  SFHFT.  
Looking at the problem again using an MDT approach has been a valuable exercise 
and I hope that the further actions give you the necessary reassurance. 

Yours faithfully 

Chief Executive 

5