Care and treatment
November 2021 to 28 April 2022
18. Mr A complains that between November 2021 and April 2022, the Trust did not provide him with either TMS or ECT treatment for his OCD (obsessive-compulsive disorder) and instead prescribed him tablets.
19. The Trust explained that initial treatment for OCD is cognitive behavioural therapy (CBT) which may include exposure-response prevention treatment and offering a selective serotonin reuptake inhibitor (SSRI) medication. If this is not effective more intensive CBT may be offered. It also said that in the event that an SSRI and CBT have not been effective the sequence of further options that may be considered is: • clomipramine (a medication) or an antipsychotic medication • a specialist inpatient service depending on the impact of the OCD and the patient’s reaction to previous treatments.
20. In relation to the use of TMS treatment for OCD, the Trust said there is guidance for this which is separate from NICE’s interventional procedures work programme. It said this guidance says that TMS should not be routinely used in the NHS because studies and trials have not produced convincing evidence that it works. The Trust said NICE guidance says the procedure should only be used in research studies and it was not involved in any research studies, nor was it commissioned to provide the treatment.
21. The Trust also said Mr A needed to engage in psychological treatment and medication for the required length of time as this would be most likely to have a positive impact and would be in line with NICE recommendations.
22. In relation to the use of deep brain stimulation (ECT) the Trust said NICE guidance for chronic, severe and treatment-resistant OCD in adults explains there is insufficient evidence to recommend the treatment in the usual treatment pathway and again it should only be considered in research studies.
23. The Trust concluded by explaining that if Mr A completed the therapy and medication regimen at the recommended level and made no progress, it could consider treatments outside the NICE guidance.
24. Relevant guidance is GMC, Good Medical Practice which explains that doctors must: • give priority to patients based on their clinical need if these decisions are in their power • give patients the information they want or need to know in a way they can understand • work in partnership with patients, sharing with them the information they will need to make decisions about their care.
25. The records show on 17 November 2021, Mr A’s GP referred him to the local mental health team. At this time Mr A was not prescribed any regular medication for his mental health such as antidepressant medication but he did take Lorazepam on an ‘as required’ basis to help him sleep. Lorazepam is a short-acting benzodiazepine medication that can reduce levels of anxiety and produce a sedative effect to help with interrupted sleep.
26. A mental health nurse contacted Mr A by telephone the same day. They noted he had previously received psychological therapy in the form of CBT but had felt it had little effect. The nurse also noted that Mr A had suffered two significant bereavements in the last year, and he had questioned whether he needed more intense therapy rather than more CBT.
27. On 18 November, the mental health nurse contacted Mr A by telephone as agreed. Mr A informed them that he wished to be referred to the Mental Health Intermediate Care Team (MHICT) for nursing input and to discuss medication options. He was also keen to consider the option of psychological therapy. The nurse agreed to make a referral to the MHICT.
28. On 14 December, a doctor in psychiatry reviewed Mr A’s case. Responding to a request to provide advice on medication options for Mr A, the doctor noted: • Mr A had reported he felt previous medications used to treat his OCD had been of limited benefit • Mr A had previously been under the care of the specialist OCD service and had received prescribed medications to treat his OCD above British National Formulary (BNF) limits • in the past Mr A had some small benefit from both sertraline and escitalopram (SSRI antidepressants) • from the information they had read, Mr A had not engaged fully with any form of psychological therapy • when consultant psychiatrists reviewed Mr A’s case in 2014 and 2015, he was not taking any regular medication for his mental health and had stated he did not want to take any.
29. The doctor recommended that if Mr A’s GP planned to prescribe sertraline or escitalopram to start him on either 25mg once daily of sertraline or 5mg once daily of escitalopram.
30. On 13 January 2022, Mr A’s GP made an urgent referral to community mental health services, noting that clinicians had referred him to ‘Let’s Talk’ (Cognitive Behavioural Therapy) in December 2021. It is recorded that the GP had increased Mr A’s prescribed dose of benzodiazepine to start an SSRI antidepressant and the GP felt Mr A needed specialist support, guidance and advice from the psychiatry team for his ongoing management.
31. A nurse dealt with the referral the same day and noted the Trust sent Mr A a letter explaining there was a waiting list to access ‘Let’s Talk’ therapy and that staff would contact him when an appointment was available. The nurse also noted there were no significant immediate risk factors associated with Mr A’s current mental health difficulties that suggested he needed a mental health assessment within 72 hours. They re-graded the referral from ‘urgent’ to ‘routine’ and also recommended a further referral be made to the Recovery Team for medication advice.
32. On 26 January, a doctor in psychiatry reviewed Mr A in person. The doctor recorded Mr A declined medication as it ‘didn’t help in the past’. The doctor challenged Mr A about this, informing him that from his medical notes they could see sertraline and escitalopram had helped a little in the past. The doctor also offered to look into the option of sertraline.
33. At the same appointment, Mr A requested TMS or ECT to treat his OCD. The doctor offered to discuss this option with a consultant psychiatrist, stating that other treatment options might be available to him before considering TMS or ECT. Mr A also asked for a longer-acting benzodiazepine compared to lorazepam. The doctor suggested diazepam but warned about the potential to become dependent on diazepam if he took it regularly.
34. As a result of the appointment on 26 January, the doctor provided a treatment plan for Mr A. They also planned to review Mr A’s previous history at the time when he was prescribed sertraline, discuss his case with the Recovery Team consultant psychiatrist, and discuss the case at a team meeting. It is recorded the doctor would contact Mr A about the outcome of their discussions with the Recovery Team.
35. On 31 January, the Recovery Team discussed Mr A and the plan was for the doctor to discuss his case with a consultant psychiatrist and for a clinical psychologist to discuss Mr A’s case at a ‘complex psychological interventions meeting’ in order to consider an assessment from the ‘complex psychological interventions service’.
36. On 2 February, the doctor discussed Mr A’s case with the consultant psychiatrist with particular reference to Mr A’s request for either TMS or ECT treatment. The consultant psychiatrist stated that ECT was not indicated for OCD and there was no evidence Mr A had any comorbid severe treatment-resistant depression, so ECT was not indicated either.
37. The consultant also told the doctor that a referral for TMS was not indicated for Mr A at this stage because he had not tried medications for the recommended duration, or psychological therapy for OCD for this latest episode of OCD symptoms. The consultant recommended that staff encourage Mr A to start antidepressant medication to treat his OCD.
38. On 3 February ‘the complex psychological interventions service’ discussed Mr A’s case and recommended to arrange an assessment either by one of ‘the complex psychological intervention’ staff on their own, or a joint assessment with a member of staff from The Recovery Team.
39. On 4 February, the doctor contacted Mr A by telephone. Mr A reported he was finding diazepam less beneficial than the lorazepam he had previously used. The doctor advised Mr A that they would ask his GP to revert to prescribing him lorazepam.
40. In the same call, the doctor informed Mr A that neither TMS nor ECT were clinically indicated for him as treatment for his OCD at the time. The doctor recommended Mr A consider going back on sertraline. Mr A declined this option or the option of any other antidepressant to treat his OCD.
41. Consequently, the doctor informed Mr A that they would provide his GP with advice around medication options for him if he changed his mind about restarting antidepressants and that they were discharging him from the care of The Recovery Team back to the care of his GP following the appointment.
42. The doctor also explained that they would be happy to review Mr A again if his GP ever re-referred him to The Recovery Team and would provide advice to either his GP or the MHICT should they ever have questions about medication options for him. Mr A asked the doctor about options for getting ECT or TMS treatment privately and they explained he could research the internet for this.
43. The doctor further informed Mr A that ‘Let’s Talk’ was happy to offer the planned therapy for Mr A and he agreed to wait for this to start. The doctor also offered to write a letter for Mr A in relation to supporting a move into alternative accommodation as the doctor felt Mr A’s current living circumstances could be a factor in his recent mental health deterioration.
44. On 9 February, the doctor spoke to Mr A’s GP by telephone following a request. The doctor told the GP that Mr A remained under the care of the MHICT and recommended ongoing input in relation to Mr A’s mental health should predominantly come from that team rather than the GP.
45. On 15 April, Mr A’s GP made an ‘urgent’ referral for him back to the community mental health services because Mr A reported he was experiencing episodes of ‘jerking’ which he felt was linked to his anxiety and was having an increasingly profound impact on his day to day life.
46. In their referral, the GP noted Mr A said he had tried more than 12 medications for his OCD over the past 10 years and felt they had caused more harm to him than benefit. Mr A also told the GP he was keen to access CBT, but he had been waiting for four months and was concerned that his OCD symptoms were worsening. It is also documented in the referral that Mr A had been looking at options for private treatment and had asked for a second opinion from a psychiatrist in Birmingham but was waiting for funding approval for this. Staff passed the GP referral to The Recovery Team.
47. On 19 April, the doctor sent a letter to Mr A’s GP advising them that he was currently under the care of the MHICT and had had an appointment with a community psychiatric nurse earlier in April. The doctor advised the community psychiatric nurse to refer Mr A to The Recovery Team or request advice on his case from The Recovery Team if necessary.
48. We asked our consultant adviser about the Trust’s actions in this period. They said that the level of responsiveness, communication and collaboration shown by the Trust was of particular note both with Mr A’s GP and him. They explained that the Trust tried to come to an agreed management plan for his OCD, incorporating social factors impacting on his clinical presentation alongside biological and psychological treatments. Our consultant adviser explained the treatment plan the doctor put in place was justified
49. We understand from our consultant adviser that the care and treatment provided to Mr A between November and 28 April 2022 was in line with relevant GMC guidance.
50. This guidance says that staff must prioritise patients based on their clinical need when they have the power to make those decisions. The nurse for example, who responded to Mr A on 17 November 2021, demonstrated this in how they responded to Mr A’s GP referral.
51. The guidance also says that staff must work in partnership with patients including giving them information that is easy to understand in order to help the patient make decisions about their care. We can see, throughout this period, staff explained to Mr A about his treatment options and advised him, for example on 26 January, of the risks associated with taking diazepam.
52. We are satisfied the Trust acted in line with relevant guidance between November 2021 to 28 April 2022 in relation to the overall care and treatment it provided to Mr A.
June 2022 to October 2022
53. Mr A says he saw a private psychiatrist on 29 April 2022 who devised a treatment plan that involved him first taking venlafaxine with a view to him having either TMS or ECT treatment if venlafaxine was unsuccessful. Mr A says the venlafaxine did not work and the Trust still would not provide TMS or ECT treatment. Mr A is concerned the Trust did not follow the private psychiatrist’s treatment plan.
54. The records show that Mr A saw a private consultant psychiatrist on 29 April 2022 who assessed him. In the ‘plan’ section of the assessment letter, the private consultant psychiatrist recommended Mr A try venlafaxine. The private psychiatrist advised that if venlafaxine did not work to ‘explore other interventions’. They also recommended that if Mr A did not respond well to the venlafaxine, or if his clinical presentation deteriorated, consideration could be given to ‘re-refer him to The Recovery Team for a longer period of assessment and support’.
55. The private psychiatrist did not make any recommendation about Mr A being considered for TMS or ECT treatment for his OCD if he failed to respond to the trial of venlafaxine. The private psychiatrist did not provide any clinical opinion about the use of either TMS or ECT to treat OCD.
56. In May 2022, the records show Mr A took venlafaxine as recommended by the private consultant psychiatrist. The Trust also provided ‘high intensity therapy’ with the Let’s Talk Team.
57. On 22 September, the high intensity therapist sent Mr A a letter informing him: • he had now completed his CBT sessions with the Let’s Talk Team • the Let’s Talk Team had discharged him • they had referred him to The Recovery Team to ‘review [his] current mental health symptoms and care plan’ • they had also re-referred him for an assessment by the ‘autism spectrum condition service’ • the nursing team at the MHICT had referred him to the complex emotional needs service.
58. On 12 October, Mr A’s GP sent a referral to community mental health services stating that Mr A had been taking venlafaxine to treat his OCD for the past five months. The GP also stated that Mr A had most recently been trialled on amitriptyline (a different antidepressant) and that he had now tried more than 14 different medications to treat his OCD.
59. NICE, Obsessive-compulsive disorder and body dysmorphic disorder: treatment, outlines how antidepressant medication and CBT are treatment options for this condition.
60. We understand from our consultant adviser that the Trust treated Mr A for his OCD in line with the NICE guidance between May and October 2022. This is because it offered Mr A a course of CBT, which he completed, and continued him on antidepressant medication.
61. We can also see that the antidepressant he was treated with during this time was that recommended by the private consultant psychiatrist on 29 April. Similarly, once Mr A completed the course of CBT, the Trust referred him to The Recovery Team which the private consultant also recommended.
62. Of note, the private psychiatrist did not recommend Mr A should be considered for TMS or ECT treatment at any point in this time including if venlafaxine proved unsuccessful. We think the Trust adhered to the treatment plan provided by the private psychiatrist for Mr A’s OCD.
ECT and TMS treatment
63. NICE, Obsessive-compulsive disorder and body dysmorphic disorder: treatment guidance, does not mention the use of ECT or TMS as treatment options for individuals with OCD.
64. NICE, Guidance on the use of electroconvulsive therapy, does not mention ECT being considered or used to treat OCD.
65. NICE, Transcranial magnetic stimulation for obsessive-compulsive disorder, states:
‘Evidence on the safety of transcranial magnetic stimulation for obsessive-compulsive disorder raises no major safety concerns. However, evidence on its efficacy is inadequate in quantity and quality. Therefore, this procedure should only be used in the context of research’
66. British Association for Psychopharmacology, Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines, does not mention the use of ECT or TMS in the treatment of OCD.
67. We are satisfied there is no guidance that identifies either ECT or TMS should be provided as treatment for OCD. We consider the Trust was justified in its decision not to offer Mr A ECT or TMS to treat his OCD.
68. In summary, we are satisfied the Trust acted in line with relevant guidance in the way it cared for and treated Mr A’s OCD between November 2021 and October 2022. We also consider it was correct not to offer Mr A ECT or TMS treatment. We will therefore take no further action.
69. Our decision is not made without recognising what a challenging time Mr A experienced with his mental health. We hope he is reassured that the Trust followed the correct guidance and also followed the treatment plan the private psychiatrist provided.
Out of county
70. Mr A says he later found out that the Trust could have referred him ‘out of county’ for ECT or TMS treatment between November 2021 and October 2022. He complains the Trust did not do this.
71. The Trust told us it neither recommends nor provides TMS treatment. It said it recognised TMS pilots are undertaken ‘out of area’ but it would have no control over whether Mr A would be accepted.
72. The Trust also explained that it is Mr A’s right under ‘patient choice’ to ask for out of area treatment if there is a clinical need to do so.
73. There is no evidence in the records that the Trust discussed ‘out of county’ treatment with Mr A between November 2021 and October 2022.
74. We have seen no specific guidance outlining that the Trust should have informed Mr A of ‘out of county’ options for either TMS or ECT treatment.
75. NICE, Obsessive-compulsive disorder and body dysmorphic disorder: treatment, outlines the treatment options recommended to treat OCD. As already explained, neither TMS nor ECT are recommended as options in this guidance.
76. Our consultant adviser explained that there was no clinical need or justification for staff at the Trust to consider a request to try treatment for Mr A’s OCD outside the above NICE guidance because the treatment options had not been exhausted. They said there were other medication options that the Trust would have needed to consider before exploring any treatment options outside of the NICE guidance.
77. We do not think the Trust did anything wrong here. The Trust followed the relevant NICE guidance in relation to Mr A’s treatment for OCD and we are satisfied there was no clinical need for it to request specific treatment for his OCD ‘out of area’.
Nurse appointments
78. Mr A complains that on several occasions between November 2021 and April 2022 a community psychiatric nurse did not take his mental health concerns seriously and failed to ask the right questions when they met with him.
79. We asked the Trust about this. It explained that the nurse was checking in with him to see how he was, whether there had been any changes, and to clarify and respond to what was said in the conversation.
80. The records show there was one appointment where the community psychiatric nurse met with Mr A during this time. This happened on 6 April 2022, following a referral from his GP to secondary mental health services.
81. The nurse recorded what was discussed with Mr A in the appointment including: • how he was feeling including his mood which was described as low with constant intrusive thoughts • that he ‘has constant worries and thoughts harming children’ • his mental health history and his medication both past and present • his daily activities and his support.
82. The nurse also documented under ‘risk to self and others’ that Mr A: • had ‘suicidal thoughts daily – children protective factor’ • ‘self harm – sometimes tears hair a little’ • ‘harm to others – thoughts of harming children’.
83. NHS England website, Mental health assessments, guidance explains that during a mental health assessment the conversation between the patient and the healthcare professional will be based around the patient’s needs. It outlines topics that the conversation might cover including ‘mental health symptoms and experiences’, ‘feelings, thoughts and actions’ and the patient’s ‘safety and other people’s’.
84. Our nurse adviser said NHS website guidance is relevant here. They explained that the assessment the nurse carried out is based on a list and statements. There is no professional curiosity or in-depth exploration about the issues mentioned, particularly around Mr A’s thoughts of harming children, where there is a lack of direct questioning. They further explained that the risk assessment the nurse carried out is very brief.
85. We understand from our nurse adviser that the assessment the nurse carried out on 6 April was not in keeping with NHS England website guidance.
86. NICE, Improving your experience of mental health services in the NHS – Information for the public explains what should happen after a clinician has assessed a patient. It outlines how a crisis plan should be developed with the patient if there is a risk of crisis.
87. Our nurse adviser also explained when Mr A told the CPN he had ‘thoughts harming children’ this was not explored enough, and no safety/crisis plan was developed. This was not in line with the NICE guidance referred to in paragraph 84.
Impact
88. Where we have seen indications of failings, we go onto consider the impact of this. Mr A says because of what happened he suffered from increased stress. We can appreciate that what happened in the appointment on 6 April would have added to the distress Mr A was experiencing in relation to his mental health at the time.
Outcomes
89. Based on our Principles for Remedy, where there have been failings leading to an injustice, public organisations should try to offer a remedy that returns the complainant to the position they would have been in, if the failings had not happened.
90. An appropriate range of remedies include: • an apology, explanation and acknowledgement of responsibility • service improvements to minimise the risk of this happening again • financial redress.
91. Mr A came to us wanting the Trust to apologise, make service improvements and pay him financial compensation.
92. In responding to the complaint, the Trust did not recognise there were indications something went wrong with the nurse’s assessment on 6 April.
93. We approached the Trust to consider whether we could resolve Mr A’s complaint at our primary investigation stage. The Trust agreed to write to Mr A acknowledging what happened.
94. The Trust also wrote to us outlining changes it has made because of what happened. This includes: • changing the digital template used to capture and record assessment conversations • introducing a scale, linked to the questions asked, so the patient can also attribute a score to how they are feeling at the time • regularly reviewing the scores • developing training for staff.
95. To determine a level of financial remedy, we review similar cases where similar injustice has arisen, along with our severity of injustice scale included in Our Guidance on financial remedy.
96. We have only seen indications of failings in relation to one aspect of Mr A’s complaint. This was one assessment. It is important to note that informed by clinical advice and relevant guidance, we have no concerns about the rest of the care he received. We consider the distress caused to Mr A because of the single appointment on 6 April does not meet the threshold for a financial remedy.
97. In summary, we consider the Trust has acted in line with our Principles in relation to the remedies it has proposed and has therefore done enough to resolve this complaint.
98. On that basis, we will take no further action because we are satisfied we have resolved Mr A’s complaint in line with our Principles for Remedy.
99. We hope Mr A is reassured by our work and by the fact the Trust has accepted what went wrong and has agreed to put it right in line with our Principles.