A practice in the Walsall area

The Practice

3. Mrs O complains in September 2022 the Practice discontinued Mr O’s prescription for apixaban, (a medicine that helps prevent blood clots), without prescribing an alternative medication.

4. Mrs O explained the impact of this was that Mr O suffered a serious thrombotic stroke and died. A thrombotic stroke is caused by a blood clot that forms inside a brain artery and blocks blood flow.

5. Mrs O is seeking financial remedy.

The Trust

6. Mrs O complains the Trust did not analyse blood tests it carried out in December 2021, until months after the tests were conducted.

7. Mrs O explained the impact of this was that Mr O suffered from a delayed diagnosis of systemic amyloidosis, leading to a shortened life expectancy. Amyloidosis is a rare disorder that happens when proteins in the body change or mutate, building up on and causing damage to organs. Systemic amyloidosis can affect any organ in the body.

8. Mrs O also complains the Trust carried out CT scans with contrast on Mr O without considering the risk these posed to his kidneys.

9. Mrs O explained the impact of this was to possibly cause a deterioration in Mr O’s kidney function.

10. Mrs O also complains the Trust agreed to Mr O’s prescription for apixaban being stopped without prescribing an alternative medication.

11. Mrs O explained the impact of this was that Mr O suffered a serious thrombotic stroke and died.

12. Mrs O is seeking financial remedy.

13. In March 2021, the Trust began treating Mr O for heart failure, and noted his thyroid function tests were out of range. The Trust requested an echocardiogram (ECG) to be performed as an outpatient.

14. The Trust diagnosed paroxysmal atrial fibrillation in May 2021 started Mr O on apixaban. Atrial fibrillation (AF) is an irregular heartbeat and paroxysmal means the episodes of AF come and go.

15. In October 2021, Mr O presented to the Trust with blood in his urine. The Trust completed inpatient monitoring, then discharged Mr O to have an outpatient CT urogram and a flexi-cystoscopy. A CT urogram is a scan that uses X-rays and contrast dye to look at the kidneys, ureters and bladder. A flexi-cystoscopy is a procedure that allows a clinician to look inside the bladder. A long, thin tube with a small camera inside is gently put into the urethra and moved through it into your bladder.

16. Due to a decline in Mr O’s kidney function, on 23 December 2021, the Trust nephrology department began investigations into possible causes. The blood results were abnormal, and the Trust wrote to Mr O to say these results would be monitored. The Trust’s serious incident report (SIR) explained this meant the tests should have been repeated in two-to-three months’ time.

17. The Trust’s nephrology department reviewed Mr O on 15 March 2022 but did not order repeat blood tests.

18. In June 2022, the haematology department saw Mr O and carried out a bone marrow biopsy, confirming a diagnosis of amyloidosis.

19. Mr O attended a clinic appointment with a Consultant Nephrologist in August 2022. During the appointment, the Trust agreed that a Peritoneal Dialysis (PD) tube would be arranged for Mr O and requested that he stopped his Apixaban. A PD tube is a tube which is surgically placed in the abdominal cavity and can be connected to a dialysis bag.

20. The Trust explained in its complaint response that Mr O was receiving Apixaban for AF. However, it stated that although AF is a prothrombotic state, meaning it increases the risk of blood clots, Apixaban needs to be stopped around the time the PD tube is inserted to reduce the risk of significant bleeding and warfarin (a different anticoagulant) can be started a week later. The Trust explained without anticoagulants there is a 3% risk of stroke compared to with anticoagulants. Anticoagulants are medicines used to prevent blood clots.

21. The consultant nephrologist had a further follow up appointment with Mr O on 30 August 2022. The consultant nephrologist and consultant cardiologist, agreed that as Mr O had paroxysmal, not permanent AF, making his risk of stroke lower, the safest plan was for Mr O to remain off anticoagulation. They planned for him to be transferred to Warfarin once the dialysis tube was inserted and the team had the results of the follow up scan.

22. In September 2022, Mr O suffered a thrombotic stroke and sadly died.

23. The Trust completed a serious incident report (SIR) into whether there had been a delay to it diagnosing Mr O with amyloidosis. It finalised the report in September 2023.

24. The SRI identified that whilst the nephrology department had initially identified the abnormal blood results, and planned to monitor these, it did not do so. The Trust did review Mr O three months later but at this review the nephrology clinic incorrectly stated Mr O’s previous blood tests were negative and did not repeat the blood tests, as it should have.

25. The SRI concluded the Trust nephrology department should have referred Mr O to haematology earlier than it did, and that in not referring Mr O sooner it caused a two-to-four-month delay in diagnosis of amyloidosis.

26. The SRI states that although systemic amyloidosis has a poor prognosis it seems likely that the delay in diagnosis shortened Mr O’s life expectancy.

29. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. This ensures the Ombudsman does not interfere with matters which are in the remit of the Courts.

30. We have discussed this with Mrs O to understand her circumstances and the outcomes she wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

31. Mrs O says that the Trust’s and Practice’s decision to stop Mr O’s apixaban prescription without replacing it with an alternative anticoagulant caused him to suffer a thrombotic stroke and die.

32. Mrs O also says that when the Trust decided to perform a CT urogram, which uses contrast dye, it did not consider the harm the contrast dye could cause to Mr O’s kidneys. She believes this could have caused the deterioration in Mr O’s kidney function, which she says occurred after the test took place.

33. Finally, Mrs O believes that by not actioning the blood test results sooner, the Trust caused a delayed diagnosis of systemic amyloidosis, leading Mr O to experience a shortened life expectancy. This is supported by the Trust’s own SRI, which found it should have made an earlier referral to haematology, and that in not doing so it caused a two-to-four-month delay in diagnosis. The SRI concluded that the Trust’s actions had likely shortened Mr O’s life expectancy.

34. Mrs O has a legal cause of action. She can pursue a clinical negligence claim against the Trust, as she is claiming Mr O’s care fell below the expected standard and was ‘negligent’. In particular the Trust shortened Mr O’s life expectancy when they did not action the blood test results in a timely manner, caused harm to Mr O while carrying out tests and caused his death by increasing his stroke risk when it stopped his anticoagulant medication.

35. Mrs O can also pursue a clinical negligence claim against the Practice, as she is claiming Mr O’s care fell below the expected standard and was ‘negligent’. In particular the Practice stopped prescribing his anticoagulants, increasing his risk of stroke and leading to his death.

36. There is a clear available legal route which Mrs O could use to potentially achieve her only desired outcome of financial remedy. We have next considered whether it is reasonable for her to pursue this.

37. Mrs O is seeking financial remedy. A clinical negligence claim is not the only way she might be able to achieve this outcome, as we might consider recommending financial remedy if we upheld the complaint.

38. Mrs O first brought her complaint to us in July 2023, shortly after receiving the Trust’s serious incident report. We discussed the case with her, and she explained she had spoken to a solicitor who informed her that she may have a cause of action. Mrs O told us she was happy to pursue this route, and we advised she could return to our service if she was unable to do so.

39. Mrs O got back in touch with us in March 2024. She explained she had spoken further to a solicitor, and they had agreed to take on the case. She explained she was not interested in this route as she was not seeking an ‘extreme amount’ of money. We explained we would reopen her case to decide whether we could consider it further.

40. We discussed the above with Mrs O when the case was reopened. Mrs O talked about the legal advice she had received and explained a solicitor told her she could potentially achieve between £10,000 and £20,000.

41. Mrs O explained she does not wish to take this route as she does not want extreme amounts of money. She said she is only seeking between £1500 and £2000. She also explained that she was worried that legal action would be a long, drawn-out process.

42. We asked Mrs O if she had any barriers that might prevent her being able to pursue this route. She explained she did not but did not intend to pursue this route if we recommended it.

43. We recognise Mrs O is concerned that the legal route might take time. It is important to note that our process is not guaranteed to be quick. Organisations will also sometimes decide to settle outside of court, which may prevent the process becoming lengthy.

44. We also recognise that Mrs O would prefer for us to look at the case, and that she is not seeking an ‘extreme amount’ of money.

45. As set out above, the law prevents us from investigating a complaint where the complainant could pursue legal action. In this case, Mrs O has a clear legal route, and it appears there are no barriers to her securing representation or pursuing this.

46. The amount of money a person is seeking is an important factor in deciding whether it is reasonable for them to pursue the legal route. We recognise Mrs O does not want the amount her solicitor has indicated. It is important to note that we make financial recommendations based on our internal guidance (the Severity of injustice scale), rather than the amount the complainant is seeking.

47. If we were to investigate and fully uphold the complaint, it is likely we would consider the impact to fall on level 6 of our scale. This involves cases where there is a potentially avoidable death and might involve a recommendation of £12,500 of more. As such, her wish for a smaller amount is not a strong reason why she should not pursue the legal route.

48. We appreciate Mrs O’s frustration and understand how difficult discussing Mr O’s care must be for her. As Mrs O did not raise any other barriers, and as Mrs O has already discussed this issue with a solicitor, we cannot say that she would be unable to do so again, either with the same solicitor a different firm.

49. In summary, there is a legal route which Mrs O could pursue to achieve the only outcome she is seeking.

50. This is something the Courts are well placed to consider, and we can see no obvious barriers which might prevent Mrs O from pursuing this.

51. We consider it is reasonable for Mrs O to pursue legal remedy. Mrs O can return to our service if she is unable to get legal representation, or if she has outstanding outcomes we can achieve following legal action.

52. If Mrs O chooses to bring the complaint back to us, we would advise she does so as promptly as possible. This is because we have a one-year time-limit by which to consider complaints (from the day a person became aware of their reason to complain). We have discretion to set this time-limit to one side if there are strong reasons to do so. We will consider the time it has taken us to consider the complaint and any other delays outside of her control.

53. We are sorry to hear of Mr O’s death and the impact this has had on Mrs O.

1. We have carefully considered Mrs O’s complaint about a practice in the Walsall area (the Practice) and Walsall Healthcare NHS Trust (the Trust).

2. We have decided to take no further action as we consider Mrs O could take legal action on the matter she has brought to us. We have set out the reasons for this decision in our statement.