A Fife man suffered a stroke after being given incorrect advice about stopping his blood thinning medication.
Following a complaint to the Scottish ombudsman, NHS Fife has been asked to apologise to the patient.
Mr C was taking rivaroxaban, a drug that thins the blood to minimise the risk of strokes, when he was scheduled for non-emergency surgery.
Because of the risk of excessive bleeding during surgery, Mr C was advised to stop taking his medication seven days before his operation.
But four days after coming off this medication, he suffered a stroke.
When he complained, the ombudsman said the board and Mr C’s consultant “appeared unclear” about whether Mr C was on rivaroxaban or warfarin.
The board said they had followed guidelines for warfarin as rivaroxaban was a very new type of medication.
They also said Mr C was classed as a low risk of having a stroke and the advice he was given was accurate and that in light of his complaint, they would develop further protocols for staff.
But Mr C said he should not have been classified as low risk and should not have been advised to stop his medication.
The ombudsman sought independent advice from a consultant geriatrician with experience in stroke medicine.
The consultant was clear Mr C was given incorrect advice about stopping these pills.
Guidelines for warfarin were not applicable to rivaroxaban and Mr C should have only been told to stop his medication for 24-48 hours before surgery.
The adviser accepted rivaroxaban was relatively new, but stressed this meant clinicians “should be more cautious and seek guidance from colleagues”.
The consultant also found the board did have specific guidelines for this drug “and there were many more available online”.
Finally, given his medical history, Mr C should have been classified as being at a moderate risk of stroke.
For these reasons the complaint was upheld, with the ombudsman also critical of the complaint investigation, which was unable to clarify whether Mr C’s consultant was aware of the type of medication he was taking.
NHS Fife director of nursing Helen Paterson said: “NHS Fife strives to provide the best possible experience for all of those requiring our care.
She said NHS Fife had implemented the recommendations in full to minimise the risk of such an incident recurring in future.
“NHS Fife treats all complaints with the upmost importance and they play an important role in informing the improvements we make to our services.
“The board has apologised to the patient involved and I welcome this opportunity to do so again.”