A practice in the Barking and Dagenham area

3. Mr A complains that a GP Practice in the Barking and Dagenham area (the Practice) unnecessarily removed his 5mg warfarin tablets (an anticoagulant medication) from his repeat prescription. He further complains that when he requested warfarin 5mg on Friday 15 September 2023 it was not received until Tuesday 19 September.

4. Mr A tells says this is causing him frustration and distress and has had an adverse impact on his mental health causing unnecessary stress and anxiety.

5. Mr A would like the Practice to follow national guidance for repeat prescriptions.

6. Mr A was commenced on warfarin in January 2014 after suffering with a pulmonary embolism (a blood clot).

7. Mr A subsequently had his international normalized ratio (INR – a measure of blood clotting times) monitored on a monthly basis with the anti-coagulation clinic. The Practice receives monthly INR monitoring sheets in the post which then get downloaded into patients' medical records and the INR recorded. INR levels help doctors know what dosage of warfarin to prescribe.

Repeat prescription

10. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong. We hope this decision provides Mr A reassurance that the Practice is following prescribing guidelines in relation to his medication.

11. The GMC guidance advises doctors:

‘You are responsible for the prescriptions that you sign. You must only prescribe drugs when you have adequate knowledge of your patient's health. And you must be satisfied that the drugs serve your patient's need.

In providing clinical care you must:

a. prescribe medicine or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health, and are satisfied that the medicine or treatment serve the patient’s needs b. provide effective treatments based on the best available evidence f. check that the care or treatment you provide for each patient is compatible with any other treatments the patient is receiving, including where possible self-prescribed over-the-counter medications.’

12. NICE guidance advises the person taking warfarin that:

• ‘It is very important to have their blood tested regularly to check their INR, at intervals agreed with the anticoagulant clinic staff.

• They should always take their anticoagulant treatment booklet ('Yellow book') when they go to the warfarin clinic to have their INR checked.

• The 'Yellow book' includes advice for people taking anticoagulants, an alert card (which the person should carry at all times), and a section for recording the INR readings.’

13. The GP is responsible for the safe prescribing of warfarin which is a powerful anticoagulant that is commonly prescribed to prevent blood clots. It is a medication with a narrow therapeutic range, meaning that the dose must be carefully monitored to ensure it is effective without causing excessive bleeding. Due to its potential for interactions with various foods, drugs, and health conditions, prescribing warfarin requires close monitoring and regular adjustments.

14. The NHS website described repeat prescriptions as medicine you can order ‘when you need it, without having to see your GP every time’. Our adviser explained that the main reason warfarin cannot be prescribed as a regular – that is, repeat - medicine without ongoing monitoring is because its effects can vary from person to person and can be influenced by factors such as diet, medications, and changes in health. To maintain its efficacy and safety, healthcare providers need to monitor INR levels regularly and adjust the dosage of warfarin accordingly.

15. The Practice must make sure appropriate monitoring and dosing advice is in place to manage Mr A’s warfarin safely. As such we consider there are no indications that the Practice has acted incorrectly by not including warfarin in his repeat prescription.

Prescription request September 2023

16. There is no national guidance for the time practice should take to action a prescription request. Our adviser says this is dictated by individual practice internal policies.

17. In this case the Practice policy requires two working days to process a prescription request. Therefore, given that Mr A submitted his request on Friday 15 September 2023 and received the prescription on Tuesday 19 September, this was processed within the time frame set out in the Practice policy. As such there are no indications of failings regarding the processing prescription.

18. We are sorry to hear about the problems Mr A has been facing, and we hope he is reassured to know there are no indications the Practice did anything wrong.

1. We have carefully considered Mr A’s complaint about his GP Practice. We have seen no indication that anything went wrong. We understand that this may be disappointing to him, and are sorry to hear about the stress and anxiety he has been experiencing.

2. Due to its potential for interactions with various foods, drugs, and health conditions, prescribing warfarin requires close monitoring and regular adjustments. We consider the Practice approach to prescribing warfarin has been in line with GMC and NICE guidance in this case.