Trust mismanaged warfarin medication

Summary 1098 |

Mr R complained that mismanagement of his warfarin medication had resulted in him suffering two strokes.

What happened

Mr R was taking warfarin for atrial fibrillation (irregular and abnormally fast heart rate). Trust staff advised Mr R to stop taking warfarin for seven days ahead of an endoscopy to examine his oesophagus. He did as advised, and suffered a stroke nine days later.

Mr R's INR (international normalised ratio – a measurement of how long blood takes to form a clot) continued to be monitored following this episode. Two years later his INR was found to be outside the normal range. His warfarin medication was changed to correct this and he continued to be monitored. Nevertheless, Mr R's INR level remained outside the normal range and he suffered a further stroke.

Mr R said that because of the strokes he can no longer work, drive or go fishing. His life has been turned upside down. He is now registered disabled and walks with a stick.

What we found

The Trust was wrong to tell Mr R to stop taking warfarin before his endoscopy. It should also have reviewed him more frequently when his INR was found to be low, and prescribed a different anticoagulant for him until his INR was in the normal range.

Mr R was at a high risk of stroke and failings by the Trust put him at an increased risk of this happening. However, because he was already at high risk because of his condition, we could not say that the mismanagement of his warfarin caused him to suffer either stroke.

Putting it right

The Trust had already apologised for advising Mr R to stop taking warfarin, and had taken steps to stop this happening again. In line with our recommendations, the Trust apologised to Mr R for the impact caused by mismanaging his warfarin when his INR was low and paid him £1,500 to recognise that opportunities were missed to reduce his risk of suffering a stroke. It also agreed to draw up plans to address this failing.

Health or Parliamentary
Organisations we investigated

Sandwell and West Birmingham Hospitals NHS Trust


West Midlands

Complainants' concerns ?

Came to an unsound decision

Did not apologise properly or do enough to put things right



Compensation for non-financial loss