12. 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 found any indications that something has gone wrong.
Management of medication
13. Mr H complains the paediatrician did not appropriately manage Master U’s medication.
14. NICE guideline NG87 says:
• to offer methylphenidate (either short or long acting) as the first line pharmacological treatment for children aged 5 years and over and young people with ADHD • to consider dexamphetamine for children aged 6 to 17 years when response to methylphenidate is clinically inadequate.
15. The Trust confirmed Master U had been on methylphenidate prior to the period complained about but he could not tolerate it and was therefore put on dexamphetamine.
16. The clinical records show Master U was on dexamphetamine 5mg/5ml oral solution. It was to be taken at a lower dose of 2.5ml three times a day. The clinical records indicate there was a discussion on 14 June 2022 around introducing propranolol to manage some of Master U’s symptoms/anxiety and then possibly increasing his dexamphetamine. It also indicates an alternative new drug for management of ADHD, Intuniv, could be considered at some point. Our adviser has said given the fluctuation of Master U’s symptoms and recent improvements the clinical records indicate this could be considered in the future if necessary.
17. On 10 July the clinical records show Master U’s mother sent an email as she wanted her son’s medication looked at urgently as he could not fall asleep and was deteriorating in terms of physical and mental health. Master U’s mother asked for a new ADHD medication by the end of Monday. The clinical records show on 11 July the paediatrician agreed to increase Master U’s evening dose of dexamphetamine to 5mg (5mls) as an interim plan.
18. On 19 July the clinical records show the paediatrician had a discussion with Master U’s mother about the recent increase in her son’s evening dexamphetamine dose to 5mg (5mls). Our adviser has said as Master U’s behavioural difficulties during the day had become more apparent it was agreed to increase Master U’s morning dose initially as there had been no side effects (funny spells, dizziness, palpations) from the increase in his evening dose. The clinical records show Master U was then prescribed dexamphetamine 5mg in the morning, 2.5mg at lunch and 5mg in the evening.
19. The clinical records show on 27 July following discussions with Master U’s mother, there had been an improvement in Master U’s condition. The clinical records say he was able to process a little better, less fight and flight but he was irritable in the afternoons with his anxiety. A decision was made to change Master U’s dose of dexamphetamine to 5mg three times a day.
20. On 19 September, the clinical records show a joint review with child and adolescent mental health services (CAMHS) took place. It indicates Master U’s sleep had improved and was sleeping through and his current medication was working at the current dose. The clinical records also show there was no side effects from his antidepressant medication, fluoxetine, his anxiety had reduced, and he was engaged with school more. The clinical records say a decision was made to continue the current dose of Master U’s medication.
21. On 6 December, the clinical records show Master U’s mother arrived at the paediatric clinic at the school even though she did not have an appointment. The clinical records say the paediatrician met with her. She reported dysregulated behaviour with inattention, impulsivity, anxiety, and emotional dysregulation. Master U’s mother also said her son’s school reports said he will need more 1 to 1 support.
22. Following this, the clinical records indicate the paediatrician liaised with the child psychiatrist seeking CAMHS advice on complex ADHD, anxiety and mood disorder as the records indicate Master U’s mother requested a change in her son’s current medication. The clinical records show the paediatrician requested CAMHS to reach a decision on switching Master U to methylphenidate.
23. On 13 December, the clinical records show advice was sought from another clinician on whether it was safe to switch Master U’s medication to methylphenidate from a cardiac point and it stated the family were in crisis. The clinical records show the clinician confirmed they were in favour of switching Master U’s medication to methylphenidate.
24. The clinical records indicate a discussion with Master U’s mother took place on 5 January 2023 to see how her son was coping on 2.5mg (lower dose) methylphenidate. The clinical records suggest Master U’s mother reported some early positive effects although brief and that her son was tolerating the medication well with no side effects. The clinical records indicate the plan was to increase the dosage to 5mg in the morning and lunchtime for the next two weeks.
25. Our adviser said the clinical records suggest Master U’s medication was appropriately managed. The consultant letters also suggest he was being monitored and that the paediatrician was liaising with the psychiatrist on his medication.
26. It is clear Master U’s mother had concerns about her son’s behaviour from the communications she had with the Trust and wanted quick responses to her concerns. We do not underestimate what a difficult and worrying time this was for her and her son. The evidence suggests, the Trust managed Master U’s condition and provided the appropriate medication in line with NICE guidance.
Lack of leadership
27. Mr H complains there was a lack of leadership in the management of Master U’s care.
28. The Trust said the management of Master U is difficult due to several parties involved as well as Devon commissioning arrangements.
29. Our adviser has said Master U’s care and treatment is complex as his care was looked after by a paediatrician and a child psychiatrist. Our adviser said this is common practice in many parts of the country and the Devon commissioning arrangements confirm this is what is specified.
30. Our adviser has said the clinician who is responsible for Master U’s main condition, which is ADHD, takes the lead. In this case it is the paediatrician. The child psychiatrist was responsible for Master U’s antidepressant medication.
31. Our adviser has explained this can potentially cause some delay in the prescribing and management of care as there are two involved clinicians, but this is a consequence of the commissioning arrangements as opposed to any fault by the clinicians.
32. GMC guidance says in providing good 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 patients’ needs • consult colleagues where appropriate
33. The clinical records show several contacts between the paediatrician and psychiatrist regarding Master U’s care. On 9 July the clinical records indicate the paediatrician had a joint discussion with the child psychiatrist about increasing Master U’s medication. There was also a multidisciplinary meeting (MDT) on 9 August.
34. On 13 September, the clinical records indicate a further joint review took place between the paediatrician and psychiatrist, and again on 6 December. This was about changing Master U’s medication to methylphenidate. The clinical records also indicate they contacted another clinician to seek their opinion on whether it was safe to prescribe methylphenidate from a cardiac point.
35. The clinical records indicate an MDT was held on 15 December to discuss Master U’s care and treatment and the plan going forward.
36. On 5 January 2023, the clinical records suggest a discussion took place with Master U’s parents to discuss and explain the management of Master U’s medication and that they are currently liaising with a sleep consultant and due to meet to discuss Master U’s joint management.
37. We understand Mr H has concerns about the leadership in his grandson’s care. The evidence suggests the management of Master U’s care was in line with the Trust’s commissioning arrangements. The evidence also suggests the clinician lead liaised with the appropriate clinicians responding to the concerns raised by Master U’s mother. This is in line with GMC guidance.
38. We thank Mr H for bringing his complaint to us for consideration. We appreciate how difficult it can be to go through the details of the complaint again. We hope we have reassured Mr H the care and treatment provided to Master U was appropriate.