3. Mrs G complained the Practice stopped her mother’s blood-thinning medication on 26 January 2021 without doing a physical examination. She was unhappy with the answers she received because the Practice’s significant event audit stated the decision to stop the medication was clinically appropriate.
4. The outcome she seeks is for the Practice to recognise it should not have stopped the medication without doing a physical examination.
5. Mrs G complained to NHS England on 16 February 2021 about the care and treatment the Practice had given her mother. She was concerned the Practice stopped her mother’s blood-thinning medication, apixaban, without examining her mother first. She was concerned this decision may have led to her mother’s sad death.
6. NHS England asked for a response from the Practice and took clinical advice to see whether what happened was in line with what should have happened. NHS England responded to Mrs G on 20 May 2021.
7. Mrs G had further questions and sent these to NHS England in June 2021. NHS England asked the Practice for further information and took further clinical advice. NHS England answered Mrs G again on 22 November 2021 but failed to send Mrs G a copy of the letter it had received from the Practice.
8. Mrs G complained to us because she was concerned the Practice had not made the improvements it should. We saw that she had not had a copy of the Practice’s letter or any information about what steps the Practice had taken. We arranged for her to see this information.
9. Mrs G came back to tell us she was unhappy with what the Practice had written on its significant event audit (SEA). This is a process to identify any patterns when serious incidents happen and consider what learning is needed to prevent such events happening again. She felt the Practice had said it would do the same again in similar circumstances. She did not believe this was in line with what NHS England had found in its investigation.
10. We asked Mrs G what she wanted to provide her with reassurance the Practice had learned from what had happened. She told us that if the Practice recognised the decision to stop the medication was based on an incomplete assessment this would resolve the matter for her.
13. We can understand why Mrs G remained unhappy when she read what the Practice had written in the SEA. We can see why she thought it did not address what NHS England had found in its investigation.
14. NHS England’s complaint response said ‘the stopping of apixaban was appropriate on the limited clinical information obtained at the time, but the doctor should have arranged for a physical assessment, the clinical assessment on which the decision to stop apixaban was taken was therefore incomplete’.
15. It is reasonable to conclude from this that the Practice should have done a physical assessment before making this decision.
16. The Practice carried out a full SEA and a review of its visiting policy. It wrote a letter explaining all the changes it had carried out.
17. The internal document that outlined the Practice discussion about what happened said ‘All were in agreement that the stopping of Apixaban with the presentation of melaena in this patient was clinically appropriate due to the suspicion of a gastro-intestinal bleed which posed greater risk to life than the risk of stroke, and that admission to hospital was recommended. A home visit to carry out a physical examination would not have changed this advice, however this was not conveyed clearly to the patient’s relative, and wasn’t documented in the patient record.’
18. Mrs G was rightly concerned about this. She explained the Practice could not know that a physical examination would not have changed what happened. She told us she wanted the Practice to recognise that it should not have stopped the medication without doing a physical examination. Mrs G said this would resolve the complaint for her.
19. We have seen a draft of a letter the Practice has written to Mrs G. This says that her mother would have benefited from a face-to-face physical assessment and the Practice should have arranged this. It says this would have led to a more complete view of the case when making any decision about stopping the medication.
20. As this was the outcome Mrs G wanted from her complaint to us, we think this is enough to resolve the matter. We will therefore take no further action. We understand the complaint is very important to Mrs G and we thank her for bringing her concerns to our attention.
1. We have carefully considered Mrs G’s complaint about a practice in the Cheshire area (the Practice). She told us she does not think the Practice has made all the changes it should following her complaint about the treatment it gave her mother. We were sorry to hear about the ongoing upset this has caused her.
2. The Practice has agreed to send Mrs G a letter to clarify what it has done since she made her complaint. We have seen this letter and it provides the information Mrs G wants. We think this is a satisfactory outcome for Mrs G.