Mr S complained that his GP Practice did not manage his warfarin medication appropriately. He felt he should have been referred to hospital earlier.
What happened
After Mr S's aortic valve replacement surgery, the anticoagulation team at the Practice took over his warfarin (medicine to reduce blood clots) management. He had unstable test results and subsequently had a stroke.
What we found
The Practice should have identified that Mr S's medical history, together with his poor test results, indicated his high stroke risk factor. The Practice should have referred him back to hospital to monitor his anticoagulation treatment. However, there was no evidence that an earlier referral would have prevented the stroke.
Putting it right
The Practice apologised for failing to refer Mr S earlier and made changes to improve its anticoagulation service.
A GP practice
West Yorkshire
Did not apologise properly or do enough to put things right
Apology