Decision Report 201406741

Summary

Mr C was taking rivaroxaban (medication that thins the blood in order to minimise the risk of a stroke) when he was scheduled for non-emergency surgery. Due to the possibility of excessive bleeding during a surgical procedure, Mr C was advised to stop taking his medication seven days prior to surgery. Four days after Mr C stopped taking his medication, he suffered a stroke.

When Mr C complained, the board and Mr C's consultant appeared unclear about whether Mr C was on rivaroxaban or warfarin (another drug used to prevent blood clots, which Mr C had previously been taking). The board said they had followed guidelines for warfarin as rivaroxaban was a very new type of medication. They also said Mr C was classed as 'low risk' of stroke and the advice he was given was accurate. They said that, in light of his complaint, they would develop further protocols for staff.

Mr C complained he should not have been classified as low risk, and should not have been advised to stop his medication. We sought independent advice from one of our advisers, who is a consultant geriatrician with specific experience in stroke medicine. The adviser was clear that Mr C was given incorrect advice about stopping his medication. Warfarin guidelines are not applicable to rivaroxaban, and Mr C should only have been advised to stop his medication for 24 to 48 hours prior to the surgery. The adviser accepted rivaroxaban was a relatively new drug, however, he stressed that this meant clinicians should be more cautious and seek guidance from colleagues if they were unclear. The adviser also noted that the board did have specific guidelines for the drug and there were many more available online. The adviser also concluded, in light of Mr C's previous medical history, that he should have been classified as being at 'moderate risk' of stroke.

For these reasons we upheld Mr C's complaints. We were also critical of the complaint investigation, which was unable to clarify whether or not Mr C's consultant was aware of the type of medication Mr C was on.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• provide us and Mr C with the updated protocols regarding rivaroxaban;
• ensure Mr C's consultant discusses this complaint as part of their annual appraisal; and
• feed back to staff the importance of clarifying at the time why a situation occurred, not retrospectively.