Delayed and incorrect diagnoses
19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event had a negative effect which the organisation has not put right. We have seen a sign something has gone wrong, but we think the Trust has arranged to put right the impact of these events.
20. Mr A told us the Trust medication review letter from March 2020 incorrectly said he had a depressive disorder. He told us the Trust sent a second letter in September 2020 to correct this.
21. Mr A told us the September 2020 letter recorded him as being diagnosed with PTSD and EUPD. He told us he should have been diagnosed with cPTSD because his condition was so serious.
22. In an email sent in September 2020, the Trust apologised for its failure to tell Mr A’s GP surgery about his PTSD and EUPD diagnoses in March 2020. The Trust apologised for the distress caused. It confirmed it had sent an updated letter to his GP surgery to confirm his diagnoses of PTSD and EUPD. The Trust has not commented specifically on whether Mr A should have been diagnosed with cPTSD.
23. We first considered whether there is any sign the care the Trust provided was not in line with relevant guidelines.
24. The GMC Guidance, paragraph 19 says: ‘Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.’
25. The Trust’s medical records show the Trust assessed Mr A on 23 January 2020. It carried out a review of his personal history. The review said several traumatic events had happened in Mr A’s past and explained the mental health issues he was suffering from. A plan was arranged to complete a medication review, where his diagnoses would be considered.
26. The Trust’s medical records show the Trust held a medication review with Mr A on 26 February and made a plan to change Mr A’s medication. The notes from the medication review do not refer to PTSD or EUPD.
27. Mr A’s GP medical records show Mr A contacted his GP surgery on 3 March. He told it he had a new diagnosis of PTSD. The Trust sent a letter saying Mr A had a diagnosis of a depressive disorder.
28. The GP surgery’s records show a discussion between the surgery and the Department of Work and Pensions (DWP) on 20 July. DWP said Mr A had said he had diagnoses of PTSD and EUPD on his PIP application form. The GP surgery advised DWP it had seen no evidence of these diagnoses.
29. The Trust sent the surgery a letter in September which corrected Mr A’s diagnoses from a depressive disorder to PTSD and EUPD.
30. We think the Trust not recording an accurate diagnosis in the first letter and the later delay in updating the clinical records was not in line with paragraph 19 of the GMC Guidance. This error is a sign of a service failing by the Trust.
31. Mr A has told us the Trust’s delay in communicating his diagnosis has caused him distress. He has also said it delayed him receiving treatment. We will consider whether the Trust had taken steps to put these impacts right in the relevant section below.
32. We can see from the records Trust did not record Mr A had a diagnosis of cPTSD, even in the corrected September 2020 letter.
33. Our adviser told us PTSD and cPTSD are two separate diagnostic categories. PTSD was the only condition included in ICD-10. ICD-10 is the main reference guide to conditions for mental health practitioners and is an NHS standard. The new category of cPTSD was included in ICD-11 (the reference guide that replaced ICD-10). The WHO endorsed ICD-11 in 2019 and it was globally implemented on 1 January 2022.
34. Considering cPTSD was not a recognised condition in the NHS in 2020, we have seen no sign the Trust failed to follow guidelines when not recording a diagnosis of cPTSD. Because we have seen no sign something went wrong here, we will not consider this aspect of the complaint further.
35. Mr A has told us the Trust’s delay in updating his diagnoses caused the DWP to initially reject his PIP application. He has also said it caused him distress.
36. Mr A has asked for service changes and financial compensation.
37. The GP surgery records show DWP sent Mr A’s surgery a request for further medical advice on 16 July. DWP then contacted the GP surgery to discuss Mr A’s PIP application on 20 July. DWP told the GP surgery that in a phone call a week before, Mr A had become aggressive with its staff and had threatened to harm himself.
38. As we know, during the 20 July call the GP surgery told DWP it did not have records of PTSD and EUPD as Mr A’s diagnoses. DWP said it was seeking further information to confirm whether his health had significantly deteriorated over the previous two years.
39. Mr A has sent us correspondence from DWP dated 10 August 2020 which shows DWP rejected his PIP application and did not award him any financial support.
40. The GP surgery records show Mr A spoke to his surgery on 19 August about his issues with DWP. He said he had problems with his PIP application, and he believed this was because his PTSD and EUPD diagnoses were not in his medical records.
41. On 2 September the GP surgery sent further medical information back to DWP. The form referred to Mr A’s mental health problems (though not explicitly PTSD or EUPD) and his physical health problems such as chronic obstructive pulmonary disease (COPD). COPD is a disease characterised by persistent respiratory symptoms like progressive breathlessness and a cough. We have seen no sign the GP surgery provided DWP with Mr A’s updated diagnoses of PTSD and EUPD between 4 September and 16 September.
42. Mr A has also sent us correspondence from DWP dated 16 September, which shows his PIP application being accepted and financial support being awarded. The letter awarded Mr A outstanding support from between January and September, together with a plan for a weekly ongoing payment.
43. Considering the timeline, DWP does not appear to have based its PIP award based on Mr A’s PTSD and EUPD diagnoses. We have seen no sign the GP surgery informed DWP of the change in diagnosis. In our view we cannot say the Trust’s delay in providing the diagnoses caused the delay with Mr A’s PIP application.
44. We can say the delay caused Mr A distress. We can see he was distressed in his call with the DWP in July and believed the problems with his PIP application were related to the absence of his PTSD and EUPD diagnoses. Although we have seen this was not accurate, the distress caused is clear. Mr A suffered distress for around six months due to the Trust’s delay in informing his GP surgery of his diagnoses.
45. We have seen the Trust has apologised for the delay in communicating Mr A’s diagnoses. We have seen no signs the Trust has changed its processes to reduce the risk of medication letters being delayed. However, the failure to write up and send the letter seems to have been an error by the reviewing consultant psychiatrist specifically. The same is true of the incorrect diagnosis in the letter.
46. We can see from the Trust’s April 2021 complaint response the consultant psychiatrist has now left the organisation. Considering the communication errors seem to have been down to a single individual who has now left, in our view there is no sign changes in procedure would help avoid this error happening again.
47. Our Principles for Remedy say: ‘where maladministration [fault] or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately’.
48. Considering this, in our view, the Trust has not yet put right the distress Mr A suffered. We have considered previous cases where we have made recommendations for financial compensation. Specifically, we reviewed similar cases where the impact is on the emotional well-being of a complainant.
49. We think the Trust should pay Mr A £100 to recognise the distress he experienced. We contacted the Trust and it agreed to pay £100 to put this impact right within eight weeks of this letter. Considering this, we think the Trust has put this aspect right and we will take no further action.
50. We appreciate this was a distressing time for Mr A. We hope this report and the financial compensation helps him to find closure on these failings.
Medication delay and incorrect dose
51. Mr A has told us the Trust did not provide information about a change of medication from fluoxetine to the prescribed venlafaxine until 7 April 2020. Fluoxetine is a medication used to treat depressive disorders, while venlafaxine is used to treat adults with depression or generalised anxiety disorder. Mr A also said the Trust did not provide his GP with accurate information on which venlafaxine dose to use.
52. The Trust said it recommended an increase in dosage of venlafaxine to 150mg, with further increases for the GP surgery to decide in line with Mr A’s needs. The Trust apologised that Mr A’s dosage had not been increased. It said if he wanted an increase in his venlafaxine dosage, he should discuss it with his surgery.
53. We considered whether the Trust’s communication was in line with relevant guidelines.
54. The GMC Guidance, paragraph 15 says, ‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must…:
b. Promptly provide or arrange suitable advice, investigations or treatment where necessary’.
55. The BNF Venlafaxine Guidance explains how venlafaxine should be prescribed: ‘Initially 75 mg once daily, increased if necessary up to 375mg once daily, dose to be increased if necessary at intervals of at least 2 weeks, faster dose titration may be necessary in some patients; maximum 375 mg per day.’
56. As we have seen, the medical records show the Trust held a medication review with Mr A on 26 February 2020. During the review, Mr A said the fluoxetine was not working and the psychiatrist prescribed venlafaxine. The medical records show the Trust sent a letter about this review to Mr A’s GP on 27 March.
57. The review letter detailed a plan for the GP surgery to prescribe Mr A fluoxetine at 30mg for one week, reducing to 20mg for one week after that. The plan then called for a washout period (a period when a patient does not receive medication) of one week and then for Mr A to start venlafaxine. The venlafaxine prescription would be started at 75mg once a day for four weeks and then increased to 150mg once a day. The surgery could then increase it based on what Mr A needed and the relevant guidelines.
58. The GP records show Mr A contacted his GP surgery himself to ask for his new medication on 6 April 2020. The surgery records show Mr A messaged again at 7.59am on 7 April. He told the GP surgery he had forgotten to mention he had now stopped fluoxetine and was starting his second week of ‘cold turkey’.
59. The GP surgery recorded it did not have any information around the new medication Mr A had been prescribed. Records show the surgery chased the Trust and received information on the prescription changes on 9 April.
60. Our adviser said the delay in the Trust providing medication information to the GP surgery was not in line with the GMC Guidance. The GMC Guidance says doctors should ‘promptly provide advice’.
61. In our view, this means there is a sign of a service failing by the Trust. We consider the impact on Mr A below.
62. The GP surgery said the prescription for venlafaxine could not be started immediately as Mr A’s blood pressure had to be checked. Records show it prescribed venlafaxine on 24 April. The surgery began prescribing 75mg of venlafaxine in line with the Trust recommendations. The surgery increased its venlafaxine prescription to 150mg on 16 July.
63. The Trust’s starting dose of venlafaxine (75mg) is recommended in the BNF Venlafaxine Guidance. We have seen nothing in the records to suggest the Trust agreed to start Mr A on a higher dose. We can see the Trust discussed increasing his venlafaxine during the medication review in February 2020.
64. We think it is likely there was some miscommunication or a misunderstanding about the starting dosage. We would be unable to determine what was said during the review. In our view the GP surgery was responsible for increasing the dosage in line with Mr A’s medical need. We will not consider the complaint about venlafaxine dosage any further.
65. We have gone on to consider whether we can see any sign this has had an impact on Mr A. He has told us the Trust’s communication delays prevented him from receiving treatment and caused him distress.
66. We can see the Trust’s delay in communication caused a delay of around a month in Mr A receiving prescriptions from his GP. Our adviser said this is likely to have delayed his recovery. We think it is likely this caused the distress Mr A has claimed.
67. We have considered whether the Trust has taken steps to put this impact right.
68. Our Principles for Remedy say where it is not possible to return a complainant to the position they were in before a failing took place, they should compensate them appropriately.
69. We can see the Trust has apologised to Mr A for the issues around the medication review and the delay in providing a correct letter to his GP surgery. We have seen no sign the Trust has altered its processes to reduce the risk of medication letters being delayed. However, we think the delay in writing the letter is likely to have been an individual error.
70. We know the psychiatrist who wrote the letter has now left the Trust. We think there is no sign changes in procedure would help avoid this error happening again.
71. Considering the above impact and the steps the Trust took, in our view the Trust has not yet put right the distress Mr A suffered.
72. We have again considered cases where we have made recommendations for financial compensation and we have reviewed similar cases. We think the Trust should pay Mr A £100 in recognition of the distress he experienced.
73. We contacted the Trust, which agreed to pay £100 to put this impact right within eight weeks of this letter. We now think the Trust has put this aspect of the complaint right and we will take no further action.
74. We understand the delays in accessing Mr A’s medication would have been distressing for him. We appreciate him taking the time to raise his concerns.
Psychiatrist discussion of complaint with surgery
75. 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 seen any sign something has gone wrong.
76. Mr A has told us the consultant psychiatrist treating him at the Trust spoke to a surgery nurse on 7 September 2020 about his complaint. He said the psychiatrist spoke to his GP on 10 September. He says this was inappropriate and meant his complaint was not properly investigated.
77. In its April 2021 response, the Trust apologised to Mr A, saying the Trust ‘is sorry that you consider [the psychiatrist] discussed your complaint with your GP’. The Trust said his GP and the psychiatrist did not actually discuss the content of the complaint. The Trust said the psychiatrist instead explained to the surgery that following Mr A’s complaint, it had reissued the medication letter (sent on 4 September) containing accurate diagnoses.
78. In the Trust’s July 2021 complaint response, it again apologised to Mr A that the psychiatrist mentioned his complaint. The Trust said the psychiatrist had reflected on the incident and would make sure they bore in mind how information was presented in future conversations with GPs.
79. We considered whether there is any sign the care the Trust provided was not in line with relevant guidelines.
80. The GMC Confidentiality Guidance, paragraph 2 says: ‘Doctors are under both ethical and legal duties to protect patients’ personal information from improper disclosure. But appropriate information sharing is an essential part of the provision of safe and effective care. Patients may be put at risk if those who are providing their care do not have access to relevant, accurate and up-to-date information about them.’
81. Our Principles of Good Complaint Handling say organisations should ‘investigate complaints thoroughly and fairly, basing their decisions on the available facts and evidence, and avoiding undue delay’. It also says: ‘Where a public body has failed to get it right and this has led to injustice or hardship, it should take steps to put things right.’
82. Our adviser said there was no specific guideline about doctors discussing complaints made against them with other clinicians. Our adviser said it is reasonable to expect information about a complaint to be treated like any other piece of information in a patient’s notes and shared with others on a need-to-know basis.
83. The GP surgery records show on 7 September 2020 the psychiatrist contacted the surgery following its enquiry about the medication review letter sent on 4 September. The records show the psychiatrist responded to this enquiry. They explained there was no change in management plans and the letter was a duplicate of the previous letter with only a change in diagnosis.
84. Our adviser said the psychiatrist had explained the background of the letter. The psychiatrist had explained the letter had been reviewed and updated following a complaint from Mr A and that he had not been reviewed again. Our adviser told us the psychiatrist provided this information to prevent any misunderstanding about Mr A’s treatment plans.
85. Our adviser said this information sharing seemed to be on a need-to-know basis. We think this was in line with the GMC Confidentiality Guidance. We understand Mr A’s concern, but we have seen no sign anything went wrong here. We will not consider whether it was appropriate to mention the ongoing complaint further.
86. We considered whether there were signs the Trust failed to investigate Mr A’s complaint appropriately.
87. We have seen the Trust responded to Mr A’s August 2020 complaint via a Patient and Liaison Service (PALS) email on 15 September 2020. PALS is a patient support service which can act as a point of contact if a patient has concerns about their treatment. The Trust provided two additional complaint responses on 15 April and 2 July 2021.
88. These responses provide answers to Mr A’s questions based on interviews with relevant staff and the available medical records. The responses also provide apologies where the Trust has identified failings. We think this is in line with our Principles of Good Complaint Handling. We have seen no sign the psychiatrist telling the GP surgery of an ongoing complaint in September 2020 affected the Trust’s investigations.
89. We appreciate it must have been distressing for Mr A to feel the Trust had not investigated his complaint appropriately.
90. We have seen no sign of a service failing by the Trust in its investigations of Mr A’s complaints. We will not consider this aspect of the complaint any further.