Refusal to prescribe diazepam
16. Mr C complains the Practice failed to provide appropriate care to him in June 2024. He says the Practice refused to give him diazepam and failed to explore treatment options for his pain.
17. We appreciate the pain, stress, and discomfort Mr C was in at the time. We understand Mr C felt he did not receive the appropriate or alternative treatment when he attended the Practice, and we acknowledge the impact this had on him.
18. To understand whether the Practice were correct in its decision not to prescribe further diazepam to Mr C and whether other treatment options were explored with him, we obtained Mr C’s medical records, sought advice from our adviser, and reviewed the relevant standards and guidance at the time of the events.
19. The records show from 28 May Mr C was suffering from a stiff neck and difficulty with movements. He was provided with diazepam to relieve the pain. Due to the ongoing pain, Mr C was seen again at the Practice and was prescribed amitriptyline, naproxen, and omeprazole.
20. He had a further telephone consultation on 3 June where he described the ongoing neck pain and lack of sleep. In the consultation he requested more diazepam. The GP advised diazepam would not be provided as it is addictive and can cause respiratory effects. The records state Mr C understood this, and amitriptyline was increased to manage the pain.
21. On 5 June Mr C called 111 due to the continued pain he was suffering from and was provided with five milligrams of diazepam.
22. On 7 June Mr C attended the Practice and requested diazepam to help with sleep deprivation. The Practice did not provide diazepam when Mr C asked for this reiterating it is not recommended as it is addictive and is not normally given for long-term muscle spasms.
23. The records indicate Mr C was not happy with the decision not to provide him with further diazepam and he became abusive and was shouting. He was asked to leave the Practice, and the police were called when he refused.
24. On 10 June, the Practice deregistered Mr C and referred him to the community physiotherapy service’s musculoskeletal department.
25. The NICE CKS on managing neck pain says a GP should consider offering medication such as ibuprofen, paracetamol or codeine, referral to a physiotherapist, providing advice on exercise options, and consider medication for neuropathic pain (pain occurring when the nervous system is damaged).
26. The NICE guidelines states ‘before starting or continuing treatment with benzodiazepine, ensure that all suitable management options, including non-pharmacological approaches and watchful waiting, have been discussed with and offered to the person’. Diazepam is a benzodiazepine.
27. The NICE guidelines also says that when making decisions about prescribing medicines, determine whether there are any factors that might increase the person's risk of developing problems associated with dependence, such as previous drug dependence.
28. By the time Mr C was seen in June, he had already been prescribed diazepam on two occasions, so the Practice refused to prescribe him any further diazepam.
29. Our adviser said it was appropriate for the Practice not to prescribe any further diazepam as this is not typically used in the management of neck pain. Our adviser said this is an addictive drug with potential side effects and interactions with other medications.
30. Our adviser also noted Mr C was known to have a previous addiction to tramadol which would make the clinician even more reluctant to prescribe more diazepam. The medical records note Mr C stated he wanted diazepam for sleep and not for pain which our adviser said added further weight not to prescribe him with diazepam.
31. Due to Mr C’s previous diazepam prescription, we consider it was reasonable and in line with the NICE guidelines for the Practice to make the decision not to prescribe any more diazepam and to provide him with alternative options instead. As diazepam is a highly addictive drug, he had already been prescribed this, and he had a higher risk of developing drug addiction due to his previous history, it was appropriate and in line with the NICE guidelines not to prescribe further diazepam.
32. When we consider whether the Practice explored other viable treatment options for him, our adviser says the Practice prescribed naproxen (an anti-inflammatory medication) and amitriptyline (for neuropathic pain) which is consistent with the recommendations for neck pain in the NICE CKS. Our adviser says amitriptyline is provided at night as it can help with sleep. We have also seen that the Practice referred Mr C for physiotherapy in line with the NICE CKS.
33. We appreciate the discomfort Mr C would have been in and appreciate it would have been upsetting and frustrating for him not to receive additional diazepam which he thought he needed to relieve his pain and help him sleep.
34. We can see the Practice acted in line with the above CKS and guidelines and provided care and treatment to meet Mr C’s needs. We therefore have found no indication of failings regarding the Practice’s decision not to provide further diazepam to him.
Action and communication taken by the Practice in asking Mr C to leave the Practice
35. Mr C says the Practice acted in a hostile way towards him when it asked him to leave the Practice. He says the Practice said if he did not leave, it would call the police.
36. We appreciate Mr C will have felt frustrated and upset by being asked to leave the Practice and the police being called.
37. On 7 June when Mr C attended an appointment at the Practice, the medical records indicate Mr C refused to leave after being denied diazepam. The records say Mr C persisted to shout at the GP and he was asked to leave the Practice. The records show Mr C became abusive and continued to shout at the GP and staff members. The Practice called the police due to this behaviour.
38. The records indicate the Practice deregistered Mr C on 10 June 2024 and at the same time made a referral to the community physiotherapy service.
39. The NHS England guidance on the scope of inappropriate and unacceptable patient behaviours says non-violent behaviours which may lead to removal from the list includes using offensive language or swearing at Practice staff, unnecessary persistent or unrealistic service demands causing disruption, and behaving in a way which causes any person to fear for their safety.
40. The NHS England guidance also says all NHS organisations have a legal duty to prevent violence in their workspaces. They can do so by identifying and preventing the escalation of distressed behaviour and promptly responding to abusive behaviour.
41. Our adviser says the Practice were reasonable in its decision to ask Mr C to leave and eventually call the police. The records indicate Mr C was verbally abusive and seemed to be intimidating. Our adviser says Mr C refused to leave the clinician’s room making her unable to see any other patients. Mr C then paced around the reception area where a receptionist reported to feel uncomfortable especially with vulnerable patients around. It is reported Mr C banged on the GP’s door. Therefore, due to the perceived intimidating and inappropriate behaviour, our adviser says the Practice were right to call the police.
42. We have seen evidence to suggest the Practice followed the NHS England guidance in handling patients who become abusive and intimidating and responding promptly to this. We therefore can see the Practice acted correctly when making its decision to ask Mr C to leave the Practice and in contacting the police when Mr C refused to leave.
43. We appreciate the distress and upset Mr C experienced, and we are sorry to hear about the experience he went through.
44. We have seen evidence to suggest the Practice acted appropriately in its decision not to provide diazepam and in its action to ask Mr C to leave the Practice. We will therefore take no further action on this complaint. We wish Mr C the best for the future and thank him for bringing his complaint to our attention.