Skip to content
recurance

Guided path, Step 1 of 4

See a chainStart

Ethel Smith Leese

7 Aug 2013 · Coroner Andrew Haigh · South Staffordshire
Check this reportOriginal

The coroner's concerns

  1. 1. inadequate address verification for anticoagulant monitoring

    “There was one matter of concern which relates to the monitoring of Mrs [name redacted] warfarin levels. The move to the care home required Mrs [name redacted] to be changed to a different GP practice. The checking by the hospital of Mrs [name redacted] address (including the address for posting for the yellow booklet) appears to have been fairly chaotic. Her address on the paperwork seems to have remained unchanged, there appears to have been doubt as to whether Cumberland House Medical Practice in Stone or the Penkridge”

Responses

No published response was found on judiciary.uk.

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error

Ethel Smith Leese · Recurance