Mrs H’s lithium levels
18. 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.
19. Mrs H complains her lithium levels were too low between 2021 and 2024. She says the Trust requested regular blood tests during this time and failed to notice and report her lithium levels being too low or change her dosage. She says this made her medication ineffective.
20. In the Trust response, it apologised for not reporting the low lithium levels to Mrs H.
21. The therapeutic range for lithium is the dosage of lithium required for effective treatment. In Mrs H’s records, her therapeutic range is noted as 0.40mmol/L to 0.80mmol/Ll.
22. We have not seen evidence in the records of Mrs H’s lithium levels being below therapeutic levels between 2021 and March 2023.
23. For example, on 7 October 2021, Mrs H’s lithium level was 0.71mmol/L. On 10 March 2022 it was 0.72mmol/L. On 15 September 2022 it was 0.58mmol/L. These examples in Mrs H’s records show her lithium levels being within the therapeutic range.
24. On 16 March 2023, Mrs H’s lithium is first reported as below therapeutic range as 0.38ml. On 19 November 2023, it was noted to be low again at 0.36mmol/L. On 15 February2024 it was 0.37mmol/L.
25. Our adviser explained all three levels were only just below the therapeutic range of 0.40mmol/L to 0.80mmol/L. The Trust’s lithium policy says a target lithium level should be recorded in the patient’s record and considered depending on clinical response and patient risk factors. It says dosage is individualised depending on clinical response. The records show the Trust appropriately recorded her target range.
26. During Mrs H’s lithium review on 8 June 2023, our adviser explained she did not show any different symptoms or signs that she was struggling more with her depression as a result of the low lithium levels. We can see the Trust noted she was well kempt and engaged in conversation well.
27. At her lithium review on 15 February 2024, Mrs H is noted to have been in good spirits, well kempt and engaging in conversation.
28. On 1 March 2024, Mrs H attended her lithium review and was advised about her lithium levels being below therapeutic levels. Mrs H explained she had a tremor and was affecting her functioning. She said she struggled to eat and hold cups. At this appointment, the Trust reduced her lithium medication and planned to reduce it further and stopping the medication.
29. The GMC prescribing guidance section 92 says doctors must make sure that suitable arrangements for monitoring, follow-up and review are in place. Section 100 says doctors should confirm that medicines are tolerated and whether there are any side effects.
30. We have seen evidence the Trust organised regular blood tests to monitor Mrs H’s lithium levels, regular lithium review appointments and noted her clinical presentation during these appointments. This is evidence that the Trust appeared to monitor her lithium levels in line with section 92 of the GMC prescribing guidance. In line with section 100, the Trust assessed her tolerance of the lithium on 1 March 2024 by considering her symptoms. Our adviser said the Trust appropriately reduced the medication to try and help these symptoms.
31. Our adviser said Mrs H who has a serum level of 0.36mmol/L and 0.38mmol/L, would be receiving some treatment benefit from the lithium, although limited. Our adviser said increasing the dosage would be considered if there were concerns about the patient’s mental state and the patient was tolerating the lithium well. In this case, they explained Mrs H was not tolerating the medication and would not be given an increase in medication.
32. Although Mrs H’s lithium level was below therapeutic level between March 2023 and March 2024, any consideration about increasing her lithium dosage would be based on her clinical presentation, mental state and tolerance of the medication. As she had a significant tremor affecting both hands, consideration would only have been given to reducing her lithium dosage. In line with section 100 GMC prescribing guidance, it appears the Trust assessed her dosage based on her tolerance of the medication by considering her side effects. The Trust’s lithium policy says side effects are usually dose dependent, so dose reductions may be beneficial.
33. We have not seen indications of failings in the Trust’s decision to not increase her medications. In line with the GMC prescribing guidance and the Trust’s lithium policy, the Trust considered her tolerance of the medication and reduced her dosage. We have also seen evidence her medication would have provided some benefit, and her medication was not ‘ineffective’.
34. We have identified an indication of failure by the Trust to communicate with Mrs H’s about her low lithium results. Section 32 of the GMC guidance says ‘you must give patients the information they want or need to know in a way they can understand. You should make sure arrangements, wherever possible, to meet patient’s language and communication needs.’
35. We have not seen evidence that Mrs H’s low lithium levels were discussed with her in her lithium review appointments on 8 June 2023, 2 November 2023 or 9 November 2023. The first documented discussion about her lithium being below therapeutic level was on 1 March 2024. The Trust should have made Mrs H aware that her lithium was below therapeutic level when it was first noticed.
36. As discussed, her lithium dosage was not increased due to her tolerance of the medication. Thus, it is likely that if Mrs H had been made aware of her low lithium levels, she would have had an increase in her medication.
37. However, we recognise how finding out about this on 1 March 2024 upset Mrs H and caused further distress and confusion about her care and treatment. We think this impact could have been avoided if the Trust discussed her lithium results with her earlier and explained the treatment plan.
38. Our NHS Complaint Standards say an organisation should identify suitable ways to put things right for people. The Trust has acknowledged that it should have communicated the lithium levels with Mrs H and apologised that this did not happen. It has said this learning will be discussed with the clinician involved.
39. Our guidance on financial remedy says lower impact cases are those where the injustice does not have a significant lasting impact. It says a case is considered a level one injustice if the person has experienced annoyance, frustration, worry and where the effect would be of short duration. We consider an apology to be an appropriate remedy for a level one impact.
40. Mrs H experienced distress and confusion when she was told about her low lithium levels on 1 March 2024. We think this impact would be considered a level one impact in line with our guidance as she has experienced a short duration of distress, and the poor communication has not caused a lasting impact. As the Trust have apologised and took learning from Mrs H’s complaint, we would consider this enough to remedy the impact and we would not recommend a financial remedy.
41. We have decided the Trust has done enough to remedy Mrs H’s impact of distress and confusion about her treatment in line with our NHS Complaint Standards and our guidance on financial remedy.
The Trust inappropriately prescribed her an antipsychotic medication
42. Mrs H complains the Practice inappropriately prescribed her Promazine and says this is an anti-psychotic drug that she does not need.
43. The Trust said promazine was used as a medication for intermittent periods of anxiety and not for a treatment of psychosis.
44. The EMC medication page for Promazine says Promazine is used as an adjunct to short term management of moderate to severe psychomotor agitation. Our adviser said this means it is licensed for use in the short-term management of agitation and anxiety and it was appropriate to be prescribed.
45. Mrs H was prescribed 25mg of Promazine on an as required basis max three times daily. This was prescribed on 24 April 2023 on an as required basis, and planned to be stopped at her review in May 2024 but Mrs H left the service. The EMC’s recommended dose for Promazine is 100 to 200 mg four times a day. Therefore, Mrs H was prescribed a dose within this recommendation dose for anxiety.
46. We understand Mrs H’s concerns about being prescribed an antipsychotic medication. We have seen evidence that Promazine can be used for short term management of anxiety and the Trust were not inappropriate to prescribe this to Mrs H. Therefore, we will not look into this any further.
The Trust did not arrange a follow up appointment in March 2024
47. Mrs H complains the Trust did not arrange a follow up appointment with her after her lithium review on 1 March 2024. She says this was to be arranged in a month to discuss her lithium reduction.
48. The Trust sent Mrs H an appointment letter on 11 April 2024 confirming a lithium review appointment on 3 May 2024.
49. In our phone call with her, Mrs H confirmed with us she did not attend the appointment on 3 May 2024, as she does not trust the Trust. She said she felt she was only offered this due to her complaint and this is why she did not go to this appointment. She says she had another appointment in November 2024.
50. Section 92 of the GMC prescribing guidance says doctors must make sure arrangements are in place for a monitoring, follow-up and review. The Trust appropriately offered Mrs H an appointment for a lithium review. We have seen evidence in the records of when Mrs H did not attend the clinic review, the Trust rang Mrs H to remind her of the appointment.
51. In line with our requirements, we look at whether something has gone wrong in the care provided. From what we have seen, the Trust provided Mrs H with a follow up appointment in line with the GMC prescribing guidance, and we have not seen evidence the Trust would not have done this but for her complaint. We are sorry Mrs H lost trust in the service and did not want to attend this appointment. We have not seen a failing as the Trust did offer Mrs H a follow up appointment on 3 May 2024 and will take no further action.
The Trust did not complete her referral to talking therapy correctly
52. Mrs H complains the Trust failed to properly refer her to the talking therapy service.
53. She says she was referred on 26 April 2024 and this was declined on 1 May 2023, because the service felt she had ‘no common mental health problem was identified’ and ‘no significant symptoms of depression’. The Trust has not provided a response to this part of the complaint.
54. We have seen evidence the Trust referred Mrs H to the talking therapy service on 26 April 2024. In this referral it states she has mental health diagnoses of emotionally unstable personality disorder and depression. It does state that she did not present with any significant depressive symptoms on 1 March 2024. In the referral it is stated she wanted to access the talking therapy service to discuss her childhood and relationship with her parents. This was listed in the referral to the talking therapy service.
55. The GMC guidance says documents used to record your work must be clear, accurate and legible. The Trust appropriately referred Mrs H to the talking therapy services including accurate information about her diagnosis and reasons for the referral in line with the GMC guidance. Our adviser felt the Trust referred Mrs H appropriately and included the relevant clinical information.
56. We have not seen evidence the Trust completed Mrs H’s referral to the talking therapy service incorrectly. From what we have seen, the Trust included all relevant clinical information in this referral. We are only considering the Trust’s referral to the talking therapy service, and we have not considered the talking therapy’s decision to decline the referral. As we have seen evidence the referral was completed correctly, we will not look into this any further.
57. We are sorry to hear Mrs H was rejected from the talking therapy service, we understand this must be very upsetting for her.