Summary: Mr C complains about the care provided to his father when blood tests showed his blood was clotting too slowly. We will not investigate Mr C’s complaint. It is unlikely we could add to the information the organisations have already shared with Mr C. An investigation is also unlikely to find the organisations actions caused a significant injustice.

The complaint

1. Mr C complains about the care provided to his father, Mr D. Specifically he complains:
• Oake Meadows Care Home (the Care Home) and College Way Surgery (the GP Practice) cannot explain why his father’s blood clotting tests (international normalised ratio - INR) were so high. He feels the explanations provided are not robust. Mr C also complains about the inaction from staff when they noted the high INR.
• NHS Somerset Integrated Care Board (ICB) did not consider all evidence when it responded to him. He says some information provided by the ICB did not conform to guidance from The National Institute for Health and Clinical Excellence (NICE).
• The discharge team from Musgrove Park Hospital (part of Somerset NHS Foundation Trust) wanted his father to go back to the Care Home because he was at the end of his life. Mr C challenged this and the Trust agreed he could go to a local hospital, where he sadly died. Mr C feels the discharge team should have known about the care provisions and should not have considered sending him back to the Care Home.
2. Mr C believes his fathers raised INR directly contributed to his death. Mr C explains he was under great stress and time pressure when the Trust wanted to discharge his father from hospital, even though he was at the end of his life and was COVID-19 positive.
3. Mr C wants a thorough medical analysis of events which provides a full explanation. He also wants compensation for the distress caused by him having to seek explanations.

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The Ombudsmen’s role and powers

4. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting for both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
5. The Ombudsmen provide a free service but must use public money carefully. They may decide not to start or continue with an investigation if they believe:

• it is unlikely they could add to any previous investigation by the bodies, or
• there is not enough evidence of fault to justify investigating, or
• any fault has not caused injustice to the person who complained, or
• any injustice is not significant enough to justify our involvement, or
• they cannot achieve the outcome someone wants.

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

6. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))

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How I considered this complaint

7. I considered written information provided to us by Mr C including copies of his complaints to the Care Home, the GP Practice and the Trust and their responses. I also considered the complaint response provided to Mr C from the ICB, and the findings of the Coroner.
8. I considered the Ombudsman’s Assessment Code.
9. I considered Mr C’s comments on my draft decision.

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What I found

Complaints against College Way Surgery and Oake Meadows Care Home

Cause of INR spike

10. Mr C is unhappy neither the Care Home or the GP Practice can explain why Mr D’s INR rate was so high. He feels their explanations that it was related to a COVID-19 infection are not enough.
11. The GP Practice, the Care Home, the ICB and the Coroner’s Office have all considered this issue, but they were unable to say what caused Mr D’s INR rate to spike.
12. As a publicly funded body we must be careful how we use our resources. We conduct proportionate investigations; completing them when we consider we have enough evidence to make a sound decision. Given the organisations that have already considered this, including the Coroner’s Office, further investigation by the Ombudsmen will not provide additional information to help resolve this issue.

Staff action when INR spike noted

13. Mr C also complains about the inaction from care workers and the doctor when they noted the high INR.
14. Mr D was taking warfarin, an anticoagulant medication used to treat blood clots and reduce the risk of heart attack and stroke. The GP Practice and District Burses monitored Mr D’s INR levels and medication. The target level in his records was between 2 and 3.
15. Mr D was tested on 24 February, 9 March, 16 March and 30 March, with no concerns. His next scheduled test was booked for 27 April.
16. On 6 April, care workers explained Mr D had a fever over the weekend and had been isolated as it could be COVID-19. They were also concerned he had problems passing urine. The doctor prescribed a 7-day course of a broad-spectrum antibiotic.
17. On 16 April a COVID-19 test showed Mr D was positive for the infection. The same day, care workers reported Mr D had a nosebleed and on 17 April, there was a small amount of blood in his urine. The doctor requested an INR test. The doctor received the result in the evening, which showed a score of 9, indicating his blood was clotting too slowly. Care workers said there had been no other bleeding and the doctor told them to stop warfarin and to send Mr D to hospital if there was.
18. Mr D’s INR level was checked again on 21 April, and it was 4.2. The doctor told care workers to keep Mr D off warfarin until his next test on 24 April. On 22 April, care workers noticed Mr D was very unwell and had noticeable weakness to his right side. They called the doctor, who told them Mr D should go to hospital. The hospital found Mr D had a severe bleed on the brain. The Care Home records do not show any falls at the Care home, so clinicians believed this was an underlying condition they were not aware of.
19. The National Institute for Clinical Excellence (NICE) provides guidance on the management of warfarin and INR monitoring. It explains warfarin should be stopped if high INR levels are recorded and testing should take place until it is back within the target range. The GP Practice and Care Home records show this was happening.
20. The Care Quality Commission says staff in Care Homes should seek advice from doctors when they are unsure of what action to take. It also stresses the importance of this for medication, “healthcare professionals continue to monitor and evaluate the safety and effectiveness of a person's medicines.” Care workers knew Mr D was taking warfarin and spoke to the doctor when they noticed he had a bleed. The doctor told the care workers what to do, and they followed the advice.
21. Care workers and the doctor followed guidance and stopped Mr D’s warfarin and then regularly checked Mr D’s INR levels. I see nothing to suggest the actions of the doctor, or the care workers was wrong and further Ombudsmen investigation would not produce a worthwhile outcome.

Complaint against the ICB

22. Mr C complains the ICB did not consider all evidence when it responded to him. He also complains some information the ICB provided did not conform to NICE guidance.
23. Mr C believes the doctor should have given his father phytomenadione, or Vitamin K. This is a group of vitamins which the body needs for clotting. It can be given to patients with a high INR level to bring the level down quickly. The ICB said in its letter 19 November 2020 that it was satisfied with the judgement made by the doctor not to give Vitamin K to Mr D. Mr C believes this is contrary to NICE guidance which recommends using it to bring down INR levels.
24. NICE state its “guidelines are evidence-based recommendations” and are to help professionals “make decisions around prescribing medicines [and] what treatments to recommend”. They are designed to be used in collaboration with the doctors clinical judgement and individual assessment of the situation.
25. The ICB explained it was a judgement call by the doctor whether to prescribe Vitamin K. The ICB has explained what happened and while I can understand why Mr C was concerned, NICE guidelines are to be used in collaboration with clinical judgement

Complaint against the Trust

26. The Trust wanted to discharge Mr D back to the Care Home, even though they knew he was at the end of his life. Mr C explains he had to remind staff of the NHS care provision and the Trust then agreed to send Mr D to a local community hospital instead. Mr C feels the discharge team should have known about ongoing NHS care provisions and should not have considered sending him back to the Care Home.
27. COVID-19 government guidelines were in place and the Trust were looking to discharge Mr D from hospital to the Care Home as soon as possible. After they spoke to Mr C, they agreed Mr D could go to a community hospital.
28. The Trust’s discharge team should have checked with Mr C before they arranged for him to return to the Care Home, but it was acting in line with guidance which was to arrange a discharge for Mr D into a home or hospice quickly.
29. This was distressing for Mr C if he did not want his father to go back to the Care Home and he had to challenge the Trust. When Mr C spoke to the team, they agreed he could go to the community hospital. However, this is not so significant and serious an impact as to warrant the use of the Ombudsmen’s resources to investigate.

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Final decision

30. The Ombudsmen will not investigate Mr C’s complaint further as there is not a realistic prospect of reaching meaningful, evidence-based findings and producing a worthwhile outcome. It is also unlikely we could find Mr C has suffered a significant injustice

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Investigator's decision on behalf of the Ombudsman