4. Miss H complains the Trust’s consultant psychiatrist changed her olanzapine medication on 11 July and 18 October 2019 (due to the side effect of weight gain) and refused to allow her to go back on it.
5. Miss H says the change in medication resulted in her being sectioned on 9 January to 30 March 2020.
6. Miss H wants an independent investigation, an apology and service improvements.
7. Miss H has been taking olanzapine medication for 30 years and has persistent delusional disorder, personality disorder (a condition that affects how you think, feel, behave or relate to other people) and schizophrenia.
8. On 11 July 2019, Miss H had her first outpatient appointment with the Trust’s consultant psychiatrist. They recorded that Miss H was very overweight, explained the risks of taking olanzapine and reduced the dose from 20mg to 10mg at night. They also prescribed 10mg aripiprazole (another antipsychotic drug) to be taken in the morning.
9. Miss H had her second outpatient appointment on 12 September. The appointment notes say, ‘that her brain is not functioning, and she is not doing very much. She is feeling giddy with the change of medication’. The psychiatrist recorded that Miss H had stopped taking her depakote (medication that can be used to treat epilepsy, bipolar disorder and migraines). They restarted this medication, reduced her olanzapine dose to 5mg and increased her aripiprazole dose to 15mg.
10. On 18 October, Miss H had her third outpatient appointment. The psychiatrist stopped her aripiprazole medication and started 1mg risperidone (an antipsychotic drug) due to Miss H and her mother complaining about and asking to go back on olanzapine.
11. In January 2020, Miss H’s mental health, mood and functioning deteriorated and she was experiencing paranoid delusion about having a brain tumour. She was unable to concentrate, had poor hygiene and was eating and drinking less. She stopped all her activities in the community and her family were becoming more concerned for her.
12. On 9 January, Miss H was detained under Section 2 of the MHA for mental health assessment and possible treatment.
13. On 30 January, Miss H was discharged and agreed to stay on the ward as an informal patient.
14. She was discharged home as an informal patient on 30 March.
Change in medication on 11 July and 18 October 2019
19. Miss H says her psychiatrist had only seen her a few times but decided to change her olanzapine medication, which she had been taking for 30 years. She explained this started her on a downward spiral and she found herself in a dark place and feeling suicidal. We are sorry to hear how seriously Miss H was affected.
20. She explained that in early 2020, she stopped eating and drinking and was sleeping a lot. The decision was made for her to be sectioned and while she was in hospital, she was prescribed a higher dose of medication which improved her mental health and she was discharged on 30 March 2020.
21. Miss H explained the alternative drugs she was switched to had exactly the same result (weight gain), so there was no benefit to changing her medication.
22. The Trust explained that the psychiatrist saw and reviewed Miss H three times (11 July, 12 September, and 18 October 2019). It explained that at the first appointment they noticed Miss H was very overweight and was taking olanzapine at the time.
23. It explained this medication carries a high risk of further weight gain and metabolic syndrome (combination of diabetes, high blood pressure, obesity, risk of heart disease and stroke). It explained the psychiatrist considered it was in Miss H’s best interests to switch her prescribed medication from olanzapine to aripiprazole.
24. The Trust said the reason for the change of medication was explained in detail to Miss H, the information was passed on to her GP and she was given a treatment advice note to give to her GP.
25. It explained at the second appointment the psychiatrist was told that Miss H had stopped taking her depakote medication, which they did not ask her to do. They restarted this medication. The plan was to review Miss H at the next appointment, in four to six weeks, to allow enough time for potential benefits of the medication changes to take effect.
26. It explained at the third appointment the psychiatrist found that Miss H had never taken risperidone and suggested it as an alternative to aripiprazole, which Miss H was convinced was not working well. They explained that starting on a new medication did not mean stopping aripiprazole completely.
27. The Trust explained Miss H’s request to go back on olanzapine was noted. The psychiatrist explained they were responsible for the medication they prescribe and that it should be in the patient’s best interests. They said this was why they started other treatments with less potential for metabolic syndrome.
28. The Trust said the psychiatrist arranged for someone to see Miss H to try to explain the reasons behind the changes in her medication because she was unhappy. It said staff explained this to her on 29 September, 21 October, 30 October and 4 November 2019.
29. GMC guidance says:
‘You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations, or treatment where necessary
…You must work in partnership with patients, sharing with them the information they will need to make decisions about their care.’
30. The Maudsley guidance says:
• ‘Weight gain is an important adverse effect of nearly all antipsychotics with obvious consequences for self‐image, morbidity, and mortality. Prevention and treatment are, therefore, matters of clinical urgency.
• …patients should be as involved as possible in decisions about the choice of medicines that are prescribed for them…
• ‘Switching [to a different antipsychotic] always presents a risk of relapse and treatment discontinuation but there is fairly strong support for switching to aripiprazole… as a method for reversing weight gain. It is possible that switching to other drugs with a low propensity for weight gain is also beneficial
• Cross taper antipsychotic with oral aripiprazole over 2 weeks.
• Amongst people with schizophrenia, non‐adherence with antipsychotic treatment is high…. Not only does non‐adherence increase the risk of relapse, it may also increase the severity of relapse and the duration of hospitalisation’
31. NICE guidance says:
• ‘The choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the carer if the service user agrees.
• The prescriber of any antipsychotic medication should provide information and discuss the likely benefits and possible side effects of each drug, including: metabolic (including weight gain).
• The prescriber should record the rationale for continuing, changing or stopping medication, and the effects of such changes.
• If a person has rapid or excessive weight gain…offer interventions’.
32. The BAP guidance says:
• ‘The fastest weight gain occurs in the first 6 months after starting an antipsychotic. Weight gain can continue after this but more slowly • ‘The risks of switching [antipsychotics] include the new medication causing side effects and being less effective for that person, leading to a relapse of their psychiatric disorder.’
33. Our decision is the Trust’s psychiatrist acted in line with the Maudsley prescribing guide in considering Miss H’s weight and how her medication might cause/contribute to this. The guide is clear that weight gain has significant consequences for patients and that switching to other drugs (with less risk of weight gain) can be beneficial.
34. We can see from the records that Miss H had a high BMI (a body mass index measures if your weight is healthy) and the psychiatrist was concerned about her weight. Our adviser explained that olanzapine tends to cause weight gain and that the psychiatrist was acting in line with the Maudsley guide in considering this. We can see the Maudsley guidance says, ‘weight gain is common and often profound’ with this medication and that aripiprazole is suggested as a potential method for reducing weight gain.
35. We can see from the records that the psychiatrist firstly reduced Miss H’s olanzapine dose from 20mg to 10mg and started her on 10mg aripiprazole. Our adviser explained they did this to safely ‘cross-taper’ the medications in line with the Maudsley guidance, making sure she received 100% of her current/maximum antipsychotic dose (following BNF guidance).
36. The records show that when reviewing Miss H on 12 September, the psychiatrist then adjusted the dose further so she had 5mg olanzapine and 15mg aripiprazole. Again, our adviser explained this was in line with BNF guidance which says 20mg is the maximum antipsychotic dose.
37. Although we can see the psychiatrist managed the dosage part of the switch correctly, our adviser raised several concerns about other parts of their decision and the way they reached it.
38. Firstly, they explained that although Miss H’s weight seemed to be linked to olanzapine, the actual risk of weight gain for this medication is highest in the first six months of taking it. This is confirmed by the BAP guidance which says, ‘the fastest weight gain occurs in the first 6 months after starting an antipsychotic. Weight gain can continue after this but more slowly’.
39. Our adviser explained that Miss H had been taking olanzapine for a very long time before July 2019. They explained her mental health had stayed stable throughout this time and this factor should have been considered before switching. We can see from the BAP and the Maudsley guidance that switching antipsychotics presents a serious risk of relapse and hospitalisation.
40. Our adviser explained the psychiatrist did not seem to act in line with NICE and GMC guidance, as they did not work in partnership with Miss H or fully take her views into account. We can see from the July 2019 records that the psychiatrist did not record Miss H’s view on her medications or the proposed switch.
41. We can also see that when the psychiatrist reviewed Miss H on 12 September, she reported she was not functioning well and feeling ‘giddy’ with the change in medication. During the next appointment on 23 October, they recorded that she, ‘wanted to go back on olanzapine due to the deterioration in her symptoms’. She reported that she felt her neighbours were linked to thoughts that she had a brain tumour.
42. Despite several requests to go back on olanzapine the psychiatrist said this would be unsuitable (due to her weight) and instead started her on risperidone. Our adviser explained this was not in line with GMC guidance. They explained that risperidone also carries a considerable risk of weight gain, so it is not clear why this was preferred to olanzapine.
43. Overall, our adviser’s view was that the psychiatrist’s decision to switch her medication was, ‘not sensible, given that she had been treated with olanzapine for many years and had remained stable in her mental state’.
44. We find the Trust’s psychiatrist failed to act in line with NICE and GMC guidance in the way they changed Miss H’s medication. Although they made sure she had a safe dose of her new antipsychotic, they failed to give proper consideration to how effective olanzapine had been for her, or to her requests to restart it when her mental health began to deteriorate.
Impact of this failing
45. We can see that Miss H stayed psychologically stable for a number of years while taking olanzapine. We can see that at the first appointment on 11 July, she stated she, ‘has just got back from holiday in Spain...that she gets rather fed up and lonely. She does go to the gym and swimming about 4 times a week in total’. At this appointment, her olanzapine medication was reduced from 20mg to 10 mg and aripiprazole 10mg was prescribed.
46. We can also see her mental state began to change after the Trust changed her medication. In September, she expressed concerns that her new medication was causing her to become giddy and in October, she explained she was not well and that she had thoughts of having a brain tumour.
47. The records from 9 January 2020 show that olanzapine had been restarted in December 2019 but that she stayed mentally unwell. The notes show, ‘her functioning has significantly deteriorated with self-neglect including poor hygiene and poor oral intake over last 3 days’.
48. The same day, we can see on her approved mental health professional report (AMHP) that the referral reason for sectioning was, ‘recent deterioration in mental health following change from olanzapine to alternative antipsychotic’.
49. CAMH guidance says, ‘antipsychotic medications…can take up to four or six weeks to reach their full effect’. This shows that although Miss H was put back on olanzapine in early December, the medication may not have taken its full effect by the end of December.
50. To summarise, we can see that in July 2019 Miss H was quite active, going to the gym and coming back from a holiday. She did not raise any concerns at that point with regards to her mental state. We can see that when the psychiatrist started to switch her medication, she started feeling unwell.
51. The most significant change happened between July and October with the gradual switch to stop her olanzapine. Her psychiatrist assessment states she started deteriorating from October 2019 and this is when her olanzapine was stopped altogether.
52. Although she was put back on this medication in early December 2019 and her mental state did not improve, we can see she was kept on this medication throughout her detention and her mental state improved.
53. We note the records from September show Miss H also briefly stopped taking her depakote medication without being asked to. Information from the NHS website and the manufacturer notes show depakote is a mood stabiliser.
54. We consider this might have had some impact on Miss H. But, our adviser gave their view that the change in antipsychotic medication and refusal to allow Miss H to restart olanzapine, was the main factor in her deterioration and being sectioned.
55. We think the changes in antipsychotic medication contributed greatly to Miss H’s deterioration and the sectioning decision.
1. We have investigated Miss H’s complaint about the decision by South West Yorkshire Partnership NHS Foundation Trust (the Trust) to change her olanzapine medication (an antipsychotic medicine used to treat schizophrenia, a long-term mental health condition) to two different antipsychotics.
2. We have found the Trust managed both changes safely in terms of dosage but failed to fully involve Miss H in decisions, or to fully consider her clinical history. Most importantly, it failed to consider these things when she asked to go back on olanzapine.
3. These failings added to Miss H’s mental health deterioration, that led to her detention under the Mental Health Act (MHA). We uphold the complaint. To put right the impact of these events, we have made recommendations at the end of this report.
56. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.
57. Our Principles say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend the Trust should write an action plan within four weeks of the date of our report, to show it will make sure the failings we found do not happen again.
58. We also recommend for the Trust to write to Miss H within four weeks of this report to acknowledge the failings and apologise to her for the impact they had.
59. We understand how much this complaint means to Miss H and are sorry to hear how the change in her medication has affected her. It is clear it has been a very difficult time.