Referral
12. Mrs I complains that the Trust changed her mental health referral of 21 November 2019 from urgent to routine, overriding her GP’s urgent referral and without telling her. She also complains that the Trust told her on 22 November 2019, she would be contacted in five to ten working days but did not contact her until she raised a complaint about the Trust on 9 December 2019. The Trust say Mrs I’s referral was downgraded on 22 November 2019 from urgent to routine with her agreement.
13. We can see from Mrs I’s GP notes that she told her GP she was suicidal, and we can see that her GP passed on these notes to the Trust’s Acute mental health team as part of the GP referral on 21 November 2019.
14. On 21 and 22 November 2019 the Trust called Mrs I following her GP’s referral. There is no recording of these telephone conversations. Mrs I says she told the Trust in these conversations that she was still feeling suicidal, and she would like some support. The Trust’s notes from these conversations refer to Mrs I’s ‘deterioration in mood’ but not specifically about her suicidal thoughts.
15. The Trust’s notes from 22 November 2019 say ‘We discussed a plan forward and [Mrs I] has agreed to a referral back to CMHT [community mental health team], she is aware that this will take time and that in the interim she will need to utilise her skills. Plan: - As discussed with [...] CMHT, [Mrs I] has been downgraded to a routine assessment’.
16. The Trust’s mental health policy says ‘urgent’ referrals should be screened within four hours of receipt or seen within 24 hours. ‘Soon’ referrals should be seen within ten working days and ‘routine’ referrals should be seen within seven weeks. The Trust’s mental health policy says an urgent referral cannot be downgraded to a soon referral unless this has been discussed and agreed with the referrer.
17. Mrs I says she was told by the Trust that she would be contacted within ten working days which from the Trust’s referral checklist appears to be in line with a ‘soon’ referral rather than an urgent or routine referral. While the Trust’s notes do not specify the timeframe in which Mrs I could expect to be contacted, we can see she complained to the Trust on 9 December 2019, immediately after the ten working days timeframe. We can see she raised concerns that she had not been contacted within five to ten working days, so it seems likely that she was given this timeframe by the Trust.
18. Following Mrs I’s complaint, the Trust contacted her on 10 December 2019 and arranged a home assessment on 12 December 2019, which is 14 working days after their conversation on 22 November 2019.
19. Our psychiatry adviser told us the Trust did not follow its own mental health policy as they should have discussed downgrading the referral with Mrs I’s GP. However, our psychiatry adviser told us rather than a clinical issue, this was more of a procedural issue.
20. Our psychiatry adviser told us based on the documentation from 22 November 2019, there is nothing to suggest Mrs I’s urgent mental health referral status needed to be maintained and the decision to downgrade Mrs I’s mental health referral at that point was appropriate. However, our psychiatry adviser was unable to comment on whether it was appropriate based on Mrs I’s recollection of what was discussed on 22 November 2019.
21. We have not seen any information to show that the Trust followed its mental health policy by agreeing with Mrs I’s GP that her referral would be downgraded from urgent. Therefore, our view is there was a failing in the Trust downgrading her referral without the agreement of her GP and in not contacting Mrs I within ten working days.
22. Mrs I says as a result she felt worse due to the stress and her mental health has been damaged. While she may not have been explicitly told her referral was downgraded, it appears she was told she would not be contacted immediately, there would be a longer wait and she would need to use her coping skills in the meantime.
23. Mrs I has told us that she thinks she should have been seen sooner, so while we know she knew the plan was for her to be contacted within ten working days, we also know this is something that Mrs I was unhappy about. Additionally, we appreciate that Mrs I was seen four working days after she was expecting after she raised a complaint about the delay. In retrospect, it is hard for us to comment on whether the outcome would have been different had the Trust contacted Mrs I’s GP about downgrading her referral, but we appreciate there was a missed opportunity for Mrs I’s GP to be involved in this decision. We recognise the delay in processing her referral may have caused her stress which may have had an effect on her mental health at an already very difficult time.
24. The Trust has introduced a welcome pack including information leaflets explaining how the mental health service operates and provides clear information to new patients. However, this welcome pack does not address what the Trust will do to prevent delays in referrals in the future or what the Trust will do to ensure its policy is followed when downgrading referrals. Therefore, we partly uphold this aspect of the complaint, and we have made recommendations for the Trust to address this.
Medication
25. Mrs I complains that the Trust recommended medication, quetiapine, on 7 January 2020 which her clinical records say she cannot have and after she had reiterated this in her home assessment on 12 December 2019 because she had previously had a bad reaction to it. From Mrs I’s clinical records on 7 January 2020, we can see the Trust initially recommended quetiapine for her. When Mrs I declined this the Trust recommended Promethazine instead, later the same day. Mrs I accepted this alternative recommendation.
26. The General Medical Council’s guidelines on good medical practice say a person’s history and views should be taken into account when assessing their condition. The General Medical Council’s guidelines on prescribing medicines say doctors should only prescribe medication if they have enough information about the patient’s health and think that the medication will benefit the patient.
27. The General Medical Council’s guidelines on prescribing medicines also say doctors should include the patient in their assessment of their condition before prescribing a medicine and they must take into account any previous adverse reaction to medicines. Our psychiatry adviser told us in initially prescribing quetiapine to Mrs I the Trust did not follow GMC’s guidelines on prescribing medicine.
28. The British National Formulary provides national advice on prescribing medication in the UK. It says ‘fatigue’ and ‘vomiting’ are common or very common side effects of all antipsychotic medication and that abnormal physical weakness or lack of energy is also a common or very common side effect of quetiapine. So we appreciate that feeling unwell after taking quetiapine is a known side effect rather than an unexpected adverse reaction. However, we would have expected the doctor to have taken into account that Mrs I had already highlighted that quetiapine was unsuitable for her as it had made her unwell in the past. This does not appear to have happened in Mrs I’s case and therefore our view is there was a failing in initially recommending quetiapine to Mrs I on 7 January 2020.
29. Mrs I feels that the Trust offering her this medication showed a lack of care and could have potentially been dangerous. We appreciate that it may have been frustrating for the Trust to suggest quetiapine to Mrs I when she had already told the Trust that it was unsuitable for her. However, we are not persuaded we can go as far as saying this issue had a lasting impact on Mrs I or caused anything other than frustration and a loss of trust in the Trust.
30. We note that Mrs I did not take the quetiapine so did not experience a physical adverse reaction to it. Also, this issue was resolved on the same day when the Trust later offered Mrs I Promethazine, as an alternative medication to quetiapine.
31. After reviewing the complaint file from the Trust, we cannot see that the Trust has reflected on this aspect of the complaint. Therefore, we partly uphold this aspect of the complaint, and we have made recommendations for the Trust to address this.
Individual psychotherapy
32. Mrs I complains that the Trust did not provide her with individual psychotherapy following her referral on 21 November 2019. Mrs I complains that the Trust would only offer her group therapy after she had explained that group therapy was unsuitable for her. She has told us this is because she has panic attacks in group settings.
33. Mrs I says she asked the Trust about individual psychotherapy, and they said she had had it before so they would not give it to her again. Mrs I says she last had psychotherapy 10 years ago and she thinks she needs a ‘top up’ and the last time she had it was good but the therapist went on maternity leave so the psychotherapy ended early. She said that she felt the Trust just treated mental health like a ‘one size fits all’ situation rather than adapting their service to individual needs.
34. The Trust says its decision to offer group therapy was based on Mrs I’s ability to use skills she had already been given in previous therapy and her ability to benefit from group therapy. It says Mrs I may have benefitted from group therapy as it enables a person to know they are not alone, that other people have similar difficulties to them and to support them thinking and feeling differently. The Trust also commented that Mrs I struggled to identify how individual therapy would help her, what her goals were or areas she would like to work on.
35. National Institute for Health and Care Excellence (NICE), which is the organisation that writes guidelines on best practice in health care, has guidelines on borderline personality disorder. They say, ‘When considering a psychological treatment for a person with borderline personality disorder, take into account the choice and preference of the service user’.
36. Our psychiatry adviser told us it does not appear that the Trust’s decision to only offer Mrs I group therapy was in line with the NICE guidelines on borderline personality disorder as the Trust provided no reason to explain why she was not considered for one to one therapy or if there was any specific consideration that individual psychotherapy was going to be unhelpful or harmful to justify declining it.
37. It seems the Trust had decided therapy would be suitable for Mrs I but not one to one therapy. However, in accordance with NICE’s guidelines on borderline personality disorder we would have expected the Trust to take into account Mrs I’s view that group therapy was not suitable for her and her preference for individual therapy when it made a decision about her treatment. From the information we have seen it does not appear that the Trust considered Mrs I’s reasons for not wanting to engage with group therapy. Therefore, our view is there was a failing in the Trust not considering Mrs I’s reasons why group therapy was not suitable for her.
38. Mrs I says as a result she felt worse due to the stress, her mental health has been damaged and she missed an opportunity for appropriate mental health treatment. We are unable to say with certainty whether individual therapy would have been offered to her if the Trust had taken into account her reasons for declining group therapy and we are unable to say with certainty whether individual therapy would have been beneficial for Mrs I. However, we appreciate that it may have been frustrating to only be offered group therapy when Mrs I had said she did not want to engage with group therapy and therefore missed the possible opportunity to engage in therapy she thinks would have been more appropriate for her.