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Failure to properly monitor warfarin bloods

Posted By CB123

"Failure to properly monitor warfarin bloods"

About: Nottingham University Hospitals NHS Trust - Queen's Medical Centre Campus Sherwood Rise Medical Centre

(as a service user),

I was discharged from hospital having just been put on Warfarin and went for a test of my INR on the Monday after the Friday on which I had been discharged. I was told I would get a phone call the next day. I didn't get a phone call, so on Wednesday morning I rang to enquire. I was told somebody would ring me back. I hadn't heard by Wednesday afternoon so I rang again.

By this time I was getting a bit worried. I finally managed to find out what my INR was on the Thursday because I was with a qualified nurse who looked it up on the computer. It was 3.0. My target was 2.0. I said that it was too high and we should contact the lab. I was told "The range is 1.0 to 5.9 so you are fine". I repeatedly insisted that it was not fine and that they had not wanted it to be as high as that.

On Friday evening I get a frantic phone call from my wife who had finally heard from the lab who had done the test. They were very worried that my INR was 3.0 on Monday since it could have carried on going up after that date. It was Friday evening so there wasn't much the lab could do but they were so worried that they told me to take NO WARFARIN AT ALL until Monday when I could be retested in clinic.

So for all I knew my INR was way too high and then, over the weekend, way too low since I took no warfarin (in my case, the risks being haemorrhaging and hepatic arterial thrombosis, respectively).

What a complete mess. Now I shlep all the way to the anticoagulation clinic at QMC and back every week because I don't trust that there won't be any more mistakes.

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Responses

Response from Nottingham University Hospitals NHS Trust 6 years ago
Nottingham University Hospitals NHS Trust

Submitted on 27/02/2018 at 10:54
Published on Care Opinion at 11:22

Thank you for sharing your experience. I’m glad you feel confident in your care at the anticoagulation clinic at our hospital, and I’m sorry to hear that you don’t feel similarly well looked after by the service at your GP practice. I hope our colleagues in the community will see this feedback you have left and be able to address the concerns you raise. If you ever have any concerns about your care at QMC or ideas for how we can improve our service, please do get in touch with our PALS team (you can call 0800 183 0204 or email PALS@nuh.nhs.uk) and we will be glad to help.

Kind regards

Andrew Steggles

Patient Experience Officer, Nottingham University Hospitals NHS Trust

Response from Sherwood Rise Medical Centre 5 years ago
Sherwood Rise Medical Centre

Submitted on 24/04/2018 at 13:59
Published on nhs.uk at 15:06

Dear patient

We are so sorry to hear of your disturbing encounter with the Practice regarding your INR results and the trauma this caused you as a result of being mis-informed.

Just to let you know that had this not been left anonymous I would have liked to have discussed this matter further with you to try to ascertain who the person at fault was and reassure you that there would be no future issues with this for you and resolve with you.

As you can probably appreciate trying to back track when there has been a while from treatment to complaint and also being anonymous it has been harder to get to the bottom of who is accountable within the Practice, so as a result we as a whole Practice take accountability and wanted to re-assure you that we have discussed this as a full team in one of our meetings with both admin and clinical staff alike. The outcome from the discussion has led to us completing a significant event form and documenting this error as both complaint and significant event,hoping that this will help us to accumulate learning outcomes from your terrible ordeal.

My sincere apologies and I now hope you are in a much healthier predicament. Please feel free to contact the Practice Manager with any further or ongoing issues who will be more than happy to communicate with you.

Kind Regards and Best Wishes

Sherwood Rise Medical Centre

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