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NHS Grampian practice ordered to apologize for patient death

SPSO found significant communication failures led to a patient dying after medication was stopped.

July 20, 2025 at 12:36 PM

Patient died from stroke after GP practice stopped blood thinning medication

A patient died from a stroke due to a failure in communication regarding medication management.

Failure to communicate led to patient's death after medication stopped

A patient died from a stroke after their GP practice stopped a prescription for blood thinning medication without a suitable alternative. The complaint was upheld by The Scottish Public Services Ombudsman (SPSO), which determined that the NHS Grampian practice failed to communicate effectively with the patient's family regarding the medication changes. There were clear indications that the patient needed the blood thinner, and it was deemed unreasonable to stop it without providing a replacement. Moreover, the practice did not carry out timely blood tests or inform relevant specialists, which breached national guidance. The SPSO ordered the GP practice to apologize and recommended immediate changes to their procedures regarding anticoagulant management.

Key Takeaways

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Patient died after GP practice stopped necessary medication without an alternative

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SPSO found poor communication and oversight by NHS Grampian

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Life-saving blood thinner medication was stopped without due process

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The GP practice was ordered to apologize and rectify their procedures

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Recommendations focus on timely blood tests and better family communication

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Focus is now on improving patient safety standards in healthcare

"The decision to stop the medication was not fully informed."

This quote highlights the negligence in decision-making by the GP practice.

"Failings were found around the administration of blood tests."

This points to systemic failures contributing to the patient's death.

"Patients should be assessed prior to the stopping of anticoagulation medication."

This emphasizes the need for proper assessments before making critical decisions.

This tragic case highlights critical flaws in communication and decision-making within healthcare settings. The failure to inform a patient's family can lead to devastating outcomes. It illustrates the pressing need for healthcare providers to follow established guidelines rigorously, especially concerning life-saving medications. The introduction of stronger protocols for communication between healthcare practitioners and families could potentially prevent similar incidents in the future. The case raises broader concerns about patient safety and the quality of healthcare services available in the public sector.