Decision report 201005309

Summary
Ms C suffers from a rare blood disorder. In 2009, she was diagnosed with mini-strokes, and prescribed medication. Tests, however, later showed that these were not the cause and clinicians decided that migraine (severe headache) was more likely. Ms C was prescribed aspirin for the long term and was taken off the initial medication. In 2009, Ms C was taken off aspirin, although it is not clear from her medical records when exactly this happened or why. She continued to experience symptoms and was admitted to hospital in 2010 having suffered a stroke.

Ms C complained that the investigations and treatment for her symptoms were inadequate. She said that the clinicians were not sufficiently alert to the symptoms and implications of the blood disorder she had, and failed to act on her prolonged symptoms. In particular, Ms C was concerned about the decisions to discontinue medication including aspirin.

We took advice from specialist neurology (nervous system) and haemotology (blood disease) advisers. They found that the board's investigations of Ms C's symptoms were appropriate and thorough, and that it was reasonable to offer treatment on the basis of migraine as the probable cause of symptoms. It appeared, however, that one of the clinicians involved decided to discontinue aspirin, but had failed to record why. Our advisers both said that continuing aspirin would have reduced the risk of future stroke.

We concluded that the decision to discontinue aspirin was poor practice and that the failure to record this decision and the reasoning behind it was not reasonable. For this reason, although other aspects of Ms C's care and treatment were appropriate, we upheld her complaint and made recommendations to address the failures identified.

Recommendations
We recommended that the board:
• review their arrangements to discontinue prescribed medication to patients to ensure this is properly recorded and reasons provided;
• draw this investigation and its findings to the attention of the clinicians involved; and
• apologise to Ms C for the failures highlighted.