An independent provider in the Stockport area

4. Mr A complains:

Trust A, Practice A and Practice B

• between 2014 and 2019 Trust A, Practice A and Practice B failed to prescribe Mr R the blood thinning drug Clopidogrel, or a similar alternative, to treat his vascular dementia.

Trust A

• around 30 October 2017 Trust A did not refer Mr R to his GP when it saw his condition had suddenly and significantly deteriorated

Practice A

• around 30 October 2017 Practice A did not make an appointment to see Mr R after his wife contacted it and said his dementia had declined very suddenly

Trust B

• in July 2018 the Trust gave Mr R an overdose of the drug Risperidone; he was given twelve tablets in one dose instead of the prescribed half a tablet, which resulted in him being unconscious for several days

Practice B

• in August 2018 a GP was flippant and dismissive during a meeting with Mr A and Mr R

• in 2018 the GP stopped Mr R’s cancer medication prematurely

• in 2018 and 2019 the GP regularly forgot to give Mr R a monthly injection prescribed to slow the progress of his cancer.

5. Mr A says there were missed opportunities to prescribe clopidogrel, and his father’s dementia progressed more quickly than it would have done otherwise and contributed to his premature death. Mr A feels guilty he did not realise Mr R should have been prescribed clopidogrel, and he lost his relationship with Mr R because of a premature decline in his dementia. Mr A says the overdose in 2018 while in the care of Trust B contributed to Mr A’s premature death.

6. Mr A also tells us he was emotionally affected by the way he and his father were spoken to by the GP at Practice B and the lack of medication prescribed by Practice B contributed to Mr R’s premature death and has caused Mr A ongoing distress and grief.

7. Mr A wants service improvements and a financial remedy.

8. Mr R was in his seventies and registered with Practice A when in November 2014 he was diagnosed with mixed dementia, which is both Alzheimer’s and vascular dementia, and prostate cancer in July 2015.

9. Mr R was admitted to Trust B on 21 July 2018. During this admission he was given a medication dose of risperidone of 2.5 milligrams instead of the prescribed dose of 250 micrograms.

10. Mr R was registered with Practice A until August 2018. He then moved into a care home and registered with Practice B until he sadly died on 15 September 2019. His cause of death was recorded as dementia and Alzheimer’s disease, and prostate cancer.

Dementia medication

14. Mr A complains that between 2014 and 2019 Trust A, Practice A and Practice B did not prescribe Mr R clopidogrel, or a similar alternative, to treat his vascular dementia. We understand from Mr A that he was told by a pharmacist he was speaking to in April 2022 about concerns relating to his mother’s care, that all people who are diagnosed with vascular dementia should be prescribed clopidogrel, or a similar alternative.

15. Dementia is a general term for a decline in cognitive function that is severe enough to interfere with someone’s daily life. Alzheimer's disease and vascular dementia are the two most common forms of dementia but have different causes. Alzheimer's disease involves the build-up of abnormal proteins in the brain, whereas vascular dementia is caused by reduced blood flow to the brain, often due to strokes or other issues affecting the blood vessels.

16. Section 16 of the GMP guidance says in providing clinical care, doctors must: • prescribe drugs or treatment, including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs • provide effective treatments based on the best available evidence.

17. The section on pharmacological interventions for non-Alzheimer dementias in the NICE guidelines on dementia does not recommend the use of clopidogrel. The NICE clopidogrel guidance says clopidogrel is recommended as an option to prevent occlusive vascular events for people who have had an ischaemic stroke or who have peripheral arterial disease, where there is plaque buildup in arteries outside the heart; or multivascular disease, which is plaque in multiple coronary arteries; or for people who have had a heart attack only if aspirin is not tolerated. Occlusive vascular events are blockages in blood vessels that stop or severely reduce blood flow.

18. We can see from records that Mr R’s GP, from Practice A up to 2018, and then from Practice B up to Mr R’s death in September 2019, took the lead in monitoring and treating his dementia. Mr R also occasionally attended a memory clinic at Trust A up to November 2017.

19. Records show that Mr R was diagnosed with ischaemic heart disease in 2009, when he was registered with Practice A. This is when blood flow and oxygen to the heart muscle are reduced. He was prescribed aspirin to treat this condition. Aspirin is a type of blood thinner which works by making the blood's platelets less ‘sticky’ to prevent the formation of blood clots that could otherwise block blood flow to the heart or brain. We can see GPs continued to regularly prescribe aspirin for Mr R up to his death in September 2019.

20. Practice A diagnosed Mr R with mixed dementia in November 2014. Mixed dementia occurs when a person has two or more types of dementia simultaneously, most commonly a blend of Alzheimer's disease and vascular dementia. As explained above, vascular dementia occurs when reduced blood flow to the brain deprives cells of oxygen and nutrients, causing damage that impairs thinking, memory, and daily functioning.

21. Mr R’s GP prescribed him memantine on 29 December 2014. Memantine is a medication used to slow the progression of moderate-to-severe Alzheimer's disease.

22. We can see from records that Mr A had annual dementia reviews at Practice A on 26 August 2015, 9 September 2016 and 25 September 2017. He continued to be prescribed memantine following each review.

23. Mr A attended Trust A’s memory clinic at on 3 November 2017. A consultant psychogeriatrician noted Mr R was currently taking memantine for the treatment of mixed dementia and they did not feel it appropriate to change his medication.

24. Mr A had another dementia review at Practice A on 17 July 2018 and his medication was not changed. Following his move to a care home some time in August, Mr R was registered with Practice B. On 28 August 2018 he was examined by the GP from Practice B who recorded they stopped memantine. The records suggest this was because the GP felt Mr R’s condition was deteriorating and they moved the focus to palliative care, i.e. care to make him more comfortable and improve his quality of life. Mr R was then seen regularly by GPs from Practice B until his death on 15 September 2019. He was not prescribed any further medication to treat his dementia.

25. We considered the matter of clopidogrel medication and whether it should have been prescribed to Mr R, with the help of our GP adviser. We understand that there is no cure for vascular dementia, and treatment focuses on managing underlying causes to slow its progression. This can include prescribing blood thinners; however, clopidogrel is not prescribed as a specific dementia treatment. We can see, in any case, that Mr A was prescribed aspirin for his heart condition both before and after his dementia diagnosis. We have explained that aspirin is a blood thinner, similar to clopidogrel.

26. We also understand that, his heart condition aside, for which he was taking aspirin throughout this period, Mr R’s medical history, both before and after his dementia diagnosis did not include any of the conditions for which the NICE clopidogrel guidance says it should be prescribed. This means there was no clinical reason to prescribe clopidogrel. Our adviser also explained it is not the case that all people with vascular dementia should be prescribed clopidogrel or similar, and so the information Mr A describes being given by the pharmacist was not accurate.

27. We have seen no indication of failings by Practices A and B and Trust A in the medication prescribed to Mr R for treatment of his dementia. The evidence available to us shows Practices A and B and Trust A followed the standards and guidelines we have referred to. We can see he was prescribed appropriate drugs based on the best available evidence, which is in line with the GMP guidance. The NICE dementia guidance does not recommend clopidogrel as a pharmacological intervention for non-Alzheimer dementias and, with reference to the NICE clopidogrel guidance, Mr A did not meet the health conditions criteria to be prescribed this drug. For these reasons we will take no further action.

28. We acknowledge Mr A’s concerns that his father was not treated with appropriate medication for his dementia. We understand he thinks the rate his father’s dementia progressed might have been slower if he had been prescribed clopidogrel. We hope to reassure Mr A that we think Trust A, Practice A and Practice B treated Mr R in line with guidance in respect of the medication they prescribed, and we have not seen anything to indicate his death was linked to any failure on their part to prescribe clopidogrel.

Other matters

29. The HSC Act says we cannot investigate complaints brought to us after one year of realising someone has a concern, unless we consider there is a good reason to do so. When we receive a complaint, we consider if it is within our time limit. This means we look at whether the complaint was brought to us within 12 months of when the complainant knew they had a reason to complain. If the complaint is outside our time limit, we consider the reasons for this. We then look at whether the explanations for the delay in coming to us were reasonable in the circumstances.

30. Mr A complained to NHS England on 15 November 2022. He made a combined complaint about all the organisations we have listed above. Greater Manchester Integrated Care Board (the ICB) took overall responsibility to respond to Mr A’s complaint on behalf of all the organisations complained about. It sent a response by email on 21 October 2024. He complained to us on 31 March 2025.

31. We have looked carefully at Mr A’s remaining complaints and considered our time limit.

Practice A and Trust A

32. Mr A complains Practice A did not make an appointment to see Mr R after his wife contacted it and said his dementia had declined very suddenly on 29 or 30 October 2017. Instead, it referred Mr R to be seen by Trust A. Mr A also complains when Trust A saw Mr R at around the same time, it did not refer him back to his GP.

33. Mr A told us he was aware in October 2017 his father’s dementia had suddenly declined. He told us he knew at the time Practice A did not make an appointment to see his father, and that Trust A did not refer Mr R to the GP, and he was unhappy about it.

34. We think this means he had reason to complain about both Practice A and Trust in October 2017.

35. Mr A therefore needed to complain to us by the end of October 2018. He did not do so until March 2025. This means his complaint is over six years outside of our time limit.

Trust B

36. Mr A complains Trust B gave Mr R a drug overdose on 21 July 2018. Mr A told us he was aware of the overdose at the time it happened. He says he knew he had a reason to complain about this issue at the time.

37. As Mr A knew he had a reason to complain on 21 July 2018, this means he should have brought his complaint to us by 21 July 2019. He complained to us on 31 March 2025. Therefore, his complaint is nearly six years outside of our time limit.

Practice B

38. Mr A complains about aspects of care and treatment Practice B provided to Mr R between 2018 and 2019.

39. We asked Mr A when he became aware of these events. He told us he knew of them as they happened. This means he needed to complain to us by: • August 2019 about the GP’s attitude at a meeting in August 2018 • sometime in 2019 regarding his concerns about his father’s cancer medication • between 2019 and 2020 about the GP forgetting to give Mr R his injection.

40. Mr A complained to us on 31 March 2025. Therefore, his complaint is between five and six years outside of our time limit for these matters.

Reasons for delay

41. We asked Mr A if he had any reasons for his delay in complaining to us. He told us he did not fully appreciate the magnitude of all the issues he has complained about, and their impact, until October 2022. His mother died in October 2022 and Mr A says it made him reflect on the care his father received. This prompted him to make his complaint to NHS England on 15 November.

42. He says the delay was compounded because he was dealing with two parents with dementia, alongside life issues associated with work and children. Additionally, he says the ICB took two years to respond to his complaint.

43. We can see the ICB replied to Mr A’s complaint on 21 October 2024. He complained to us on 31 March 2025. We asked Mr A why he took five months to complain to us after receiving his response. He told us he did not read the email until sometime in March 2025 because he did not realise it was in his inbox.

44. We acknowledge Mr A’s explanation for the delay in coming to us. We note that he says he did not feel he fully understood the importance of his complaint until October 2022. We have not seen that concerns about his mother’s care at that time were connected to the matters he has raised about his father’s care several years previously, so we cannot agree that he was unaware of cause for complaint until October 2022. He has confirmed that he was aware when these events took place that he was unhappy with the actions of the organisations involved, and we have not seen any new information came to light after that time that he did not already have.

45. Setting aside the time the ICB took in trying to resolve his complaint (23 months and one week), we can see his complaint was considerably outside of our time limit even before he made his complaint to NHS England.

46. We understand daily life and caring responsibilities are time consuming and can make pursuing a complaint challenging. We have not seen that this is sufficient reason for a delay of five to six years, perhaps with the support of a free NHS advocacy service, which can help with the organisation and communication of making a complaint. Where the five-month period after receiving his response is concerned, we must explain that the responsibility for reviewing email correspondence lies with the person complaining, so we cannot accept this as being a strong reason for delay.

47. We can see no strong reason why Mr A was not able to complain about these matters any sooner than November 2022 or bring his complaint to us sooner than he did. We are not able to set aside our time limit in this instance and so will not be looking at these matters further.

48. We acknowledge Mr A’s concerns about the care and treatment given to his father between 2014 and 2019. We can see his complaint is very important to him and we hope we have clearly set out how we reached our decision in this case.

1. We have carefully considered Mr A’s complaints about Pennine Care NHS Foundation Trust (Trust A), two GP practices in the Stockport area (Practice A and Practice B) and Stockport NHS Foundation Trust (Trust B). It is clear that the concerns he raises about the care and treatment provided to his father, Mr R, continue to cause him distress.

2. Having done so, we have seen nothing to suggest Trust A and Practices A and B failed to act in line with applicable guidelines and standards in the way they managed Mr R’s medication. We can see his complaint about Trust B, and other complaints about Trust A and Practices A and B, fall outside of our time limit and we are not able to set it to one side. Therefore, we will take no further action on Mr A’s complaints.

3. We hope the explanations below reassure Mr A we have taken his concerns seriously and carefully considered them. We were very sorry to hear of the sad circumstances which led to his complaint and offer our sincere condolences on the loss of his father. We do not underestimate how difficult things have been for Mr A or to diminish the impact these events have had on him.