A practice in the Bury area

3. Mrs R complains about the care and treatment she received from the Practice between 2018 and 2021. She says the Practice failed to prescribe fluoxetine in a timely manner to treat her tics, body jerks, facial drooping and fatigue.

4. As a result, Mrs R says she suffered unnecessarily for three years. She says the decline in her health caused her distress and embarrassment, and impacted her confidence. Mrs R says she also suffered from numerous falls.

5. By bringing the complaint to us, Mrs R is seeking financial compensation.

2018

6. Mrs R had been prescribed citalopram (a type of antidepressant known as a selective serotonin reuptake inhibitor) in 2006 for depression and anxiety. She had been actively taking this medication for 12 to 13 years. Her dosage varied but had been around 30mg since 2013.

7. In August 2018, Mrs R came to the Practice with a two-day history of facial weakness. This was the first time Mrs R had had this symptom.

8. Due to the sudden onset of neurological loss, the Practice contacted the on-call stroke registrar at the local hospital for further advice. It recommended the Practice start Mrs R on 300mg of aspirin and refer her urgently to the stroke clinic. The stroke team could not find any cause for her symptoms and diagnosed Mrs R with functional facial weakness (functional weakness is a condition where a person has weakness or paralysis in part of their body or their whole body, with no identifiable damage to the neurological system).

2019

9. On 30 August 2019, Mrs R went back to her GP with left facial side drooping. The GP arranged a private referral to neurology. The neurologist reported Mrs R had a functional neurological disorder and did not prescribe fluoxetine or mention anything about citalopram potentially being the cause of her symptoms.

10. On 15 November, Mrs R had a medication review at the Practice. She reported her mood was good, she was having cognitive behavioural therapy (a talking therapy which can help a person manage their problems by changing the way they think and behave, most commonly used to treat anxiety and depression but also useful for other mental and physical health problems) and it was agreed she would continue with citalopram.

2020

11. On 19 February 2020, Mrs R had an annual medication review over the telephone. She reported she was stable on citalopram and the plan was to continue on this medication.

2021

12. On 30 September 2021, Mrs R had a telephone consultation with the Practice to review her citalopram. The Practice noted she was still taking 30mg. The British National Formulary advises a maximum dose of 20mg for older people due to its effects on the heart. As Mrs R had a pre-existing heart problem, the Practice recommended a reduction in her dosage and put it down to 20mg. It arranged to review Mrs R two months later.

13. On 10 October, Mrs R had a second consultation with the Practice. Mrs R reported, since the reduction in citalopram from 30mg to 20mg, she had been feeling unwell and dizzy. At this stage the doctor stopped the citalopram and changed Mrs R’s medication to fluoxetine, as suggested in the previous consultation on 30 September.

17. Mrs R says she visited the Practice numerous times between 2018 and 2021. During this time she complained of symptoms including tics, facial drooping and falls.

18. Mrs R complains that, despite her concerns, the Practice failed to prescribe her fluoxetine to treat her symptoms until October 2021. Mrs R believes citalopram (which she had been actively taking for the last 13 years) was the reason for the sudden deterioration in her health.

19. She wants to know why the Practice did not stop her citalopram medication as soon as she came to the Practice with her symptoms. She also wonders why the Practice did not prescribe her fluoxetine sooner.

20. To help us reach a decision on Mrs R’s concerns, we submitted relevant sections of her medical records to our adviser. We wanted to understand more about the care and treatment the Practice provided to Mrs R and whether its explanation for her concerns is correct and in line with clinical guidelines.

21. We asked our adviser if, within the records, there is any evidence to show Mrs R complained of the symptoms she described. We asked this because Mrs R told us she reiterated her symptoms to the Practice numerous times between 2018 and 2021, yet the Practice ‘ignored’ her.

22. Our adviser noted throughout this period Mrs R came to the Practice with the following symptoms:

• 18 January 2018: lump on nose • 22 May 2018: lump on chest • 17 August 2018: left facial weakness and tingling • 11 January 2019: facial drooping, improving • 12 April 2019: mild sensory changes in feet • 29 April 2019: stress, facial drooping, lump in abdomen • 15 May 2019: fatigue • 24 May 2019: numbness in feet • 30 August 2019: facial droop, weak and sluggish left side of body • 7 April 2020: fatigue • 4 August 2020: cold feet, shortness of breath • 24 August 2020: shortness of breath • 2 August 2020: shortness of breath • 30 September 2020: irregular heartbeat and chest discomfort • 10 March 2021: pains in calves • 11 May 2021: speech tics, balance problems and fatigue • 20 September 2021: pressure in lower abdomen • 30 September 2021: tics, stammer • 11 October 2021: dizziness, feeling unwell.

23. Here we can see there are occasions where Mrs R came to the Practice with tics, facial weakness/drooping and balance problems. We then looked at what the Practice did and whether its actions were in line with clinical guidelines.

24. Records show when Mrs R first came to the Practice in August 2018, due to the sudden onset of neurological loss, the Practice contacted the on-call stroke registrar at the local hospital for further advice. It recommended the Practice start Mrs R on 300mg of aspirin and refer her urgently to the stroke clinic. The stroke team could not find any cause for Mrs R’s symptoms and diagnosed her with functional facial weakness.

25. In 2019, records show Mrs R went back to the Practice, where she reported worsening of her symptoms. Here we note the Practice referred Mrs R to a consultant neurologist for further investigation of her symptoms. The neurologist diagnosed Mrs R with functional facial symptoms and functional movement disorder.

26. The relevant guideline here is GMC’s Good Medical Practice, which states: ‘You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:

• promptly provide or arrange suitable advice, investigations, or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’

27. We can see the Practice acted in line with this guideline, because the Practice quickly referred Mrs R to two separate specialists for further investigation of her symptoms. This included specialists within the stroke team and a private referral to a consultant neurologist.

28. We then looked at Mrs R’s concern that the Practice failed to identify that citalopram was the reason for the sudden deterioration in her health and, despite her symptoms, failed to provide fluoxetine sooner.

29. Our adviser confirmed there is no clinical indication which says fluoxetine can be used to treat the symptoms Mrs R described, so it would not have been appropriate for the Practice to change her medication from citalopram to fluoxetine without further evidence to suggest otherwise. This is supported by the British National Formulary, which states fluoxetine is only prescribed to treat:

• major depression • bulimia • obsessive compulsive disorder, and • menopausal symptoms.

30. Further, as explained above, in 2019 a consultant neurologist diagnosed Mrs R with a functional neurological disorder and did not identify citalopram as a contributory factor to or a cause of Mrs R’s symptoms. The neurologist also did not suggest changing Mrs R’s medication from citalopram to fluoxetine.

31. As the neurologist told the Practice Mrs R’s symptoms were the result of a functional neurological disorder and not citalopram, our adviser explains the Practice’s explanation that it accepted this diagnosis is appropriate. This is because a specialist often knows best how to treat neurological disorders in their specialist field. This is supported by Good Medical Practice, which states: ‘You must work collaboratively with colleagues, respecting their skills and contributions’ and ‘In providing clinical care, you must:

• prescribe drugs or treatment, including repeat prescriptions, only when you 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.’

32. Taking all this into account, we can’t support Mrs R’s complaint that the Practice failed to prescribe fluoxetine in a timely manner to treat her tics, body jerks, facial drooping and fatigue.

33. As stated above, the British National Formulary does not list fluoxetine as a medication for treating facial drooping or tics. In line with Good Medical Practice we can see, when Mrs R came to the Practice with her symptoms, it arranged suitable referrals to specialists for further investigation.

34. As explained above, it would not have been appropriate for the Practice to prescribe fluoxetine to treat Mrs R’s symptoms, as the British National Formulary states the drug is only used to treat mental health issues and symptoms of the menopause. On this basis, we are satisfied there are no signs of failings regarding the care the Practice provided, and we cannot support Mrs R’s complaint that the Practice failed to prescribe fluoxetine in a timely manner.

35. We appreciate Mrs R’s feels strongly about her complaint and is deeply concerned about the care she received. We do not underestimate the impact she says these events have had on her.

36. We have not seen any signs of failings by the Practice. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for it.

1. The Parliamentary and Health Service Ombudsman has carefully considered Mrs R’s complaint about a practice in the Bury area (the Practice). The complaint relates to the care and treatment she received between 2018 and 2021.

2. We are very sorry to hear about the circumstances which led Mrs R to approach us. We have completed our consideration of her complaint and decided we will not be taking any further action. We recognise how distressing this experience has been for Mrs R and do not wish to downplay this. We hope Mrs R finds our explanation helpful and it does not cause her any further distress.