Decision Report 201508615

Summary

Mr C had been taking warfarin (a blood-thinning medication). Following a review at an out-patient cardiology clinic, his International Normalised Ratio (INR, a blood test that checks how long it takes for blood to clot) target range was changed to between 2 and 3. Previously, it had been 2.5 to 3.5. Mr C's GP practice did not update the change on their systems and Mr C only became aware of the change 18 months later. Mr C complained to the practice and was dissatisfied with their handling of his complaint.

Whilst the practice accepted that they failed to update Mr C's INR target, the advice we received was that this failing was not significant. The adviser said the change in Mr C's INR target was not clearly communicated by the cardiologist to the practice as it did not contain a sufficient alert to notify the change in his INR target level. Furthermore, the practice could not be expected to be aware of national changes. We accepted this advice. The adviser also commented that as Mr C's INR target was to be reduced rather than increased, there was no significant clinical risk resulting from the failure of the practice to update the target. Taking account of this advice, we did not uphold this aspect of the complaint.

We accepted that the practice had provided Mr C with an apology and an explanation for the error but they had delayed in doing so. While we accepted the delay was due to difficulty in obtaining information that they needed from the cardiology department, we considered the practice could have made Mr C aware of this. We also found that the practice's response to Mr C's complaint did not contain details for this office. We upheld this aspect of the complaints.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings in complaints handling identified in this investigation; and
• review their complaints handling procedures to ensure that they are in line with NHS Scotland's 'Can I Help You?' guidance.