Mrs V had an operation at the Croydon Health Services NHS Trust (the Trust – formerly Mayday Healthcare NHS Trust). After a previous operation there, she developed blood clots because the Trust had not properly managed her anticoagulant medication. This time, she was worried about not receiving the right medication, so the Trust agreed that she could go home on the day of the operation and manage her own medication.

However, the discharge letter explaining this did not reach Mrs V’s ward and she was kept in hospital overnight. Staff did not deal with her anxious requests for her anticoagulant medication. As Mrs V’s husband said, ‘my wife fully understands her need for correct daily medication ... She “knows” her own body well’. He felt ‘petrified’, ‘helpless’ and fearful that his wife’s life was in danger.

Just days after Mrs V was discharged she returned limping and in pain. She was readmitted to hospital and found to have blood clots. Mrs V had to use crutches for several weeks, and relied on her husband to do everything for her.

When we investigated, Mr and Mrs V said they were pleased that finally ‘someone was actually listening to us’. We found breakdowns in communication about Mrs V’s discharge and her medication, and a succession of failures in her care. All of this increased her risk of developing blood clots. The Trust failed to acknowledge that Mrs V had been readmitted to hospital and that the lack of her medication might have contributed to this.

Eventually the Trust apologised to Mr and Mrs V for their poor care and treatment and for their complaint handling. They also drew up plans to prevent the same mistakes happening again, including introducing guidelines for prescribing anticoagulant medication. The Trust also paid Mrs V £5,000 for the injustice caused.