22. 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.
Medication 23. Mr K and Miss C complain the Trust’s CAMHS team delayed prescribing him with medication which was recommended by the SCAAND team in July 2024. We are sorry to hear about the events that led them to raise a complaint. Understandably, Miss C is concerned it missed an opportunity to prescribe Mr K with medication earlier, as his symptoms worsened, and he was admitted to the Trust in August.
24. GMC guidelines say, if you prescribe based on the proposal or recommendation of another healthcare professional, you must be satisfied the prescription is needed, appropriate for the patient, within the limits of your competence and that you have enough information to safely proceed.
25. Mr K’s records show the SCAAND team assessed him on 6 June. On 5 July it emailed a summary of its findings to Mr K, his mother and the Trust’s CAHMS team which included recommendations on how to manage Mr K’s weight loss. It did not suggest a prescription for medication at this time.
26. The SCAAND team issued its final assessment report on 24 July, which recommended the Trust consider a prescription for sertraline to treat Mr K’s anxiety. Sertraline is a medication used to manage and treat social anxiety disorder.
27. The SCAAND team emailed the Trust on 12 August and recommended it consider prescribing Mr K with medication such as Risperidone to relieve Mr K’s distress related to the death of his pets, if it considered it was appropriate. Risperidone is used to treat several conditions including irritability associated with ASD. It is important to note the Trust admitted Mr K on 14 August with acute food refusal and discharged him on 21 August.
28. On 14 August Miss C requested the Trust transfer Mr K to a doctor in different CAHMS team within the Trust. The Trust agreed to the transfer request, and he was transferred to a different team with the doctor specifically requested, on 21 August.
29. The Trust noted Mr K was in crisis and prescribed him with risperidone on 30 August. Mr K attended his first appointment with his new doctor and care coordinator on 12 September. It agreed to obtain all handover notes from his previous team and review all reports. It also agreed to continue his prescription for risperidone.
30. Based on the evidence up to this point, the doctor who initially prescribed Mr K with risperidone had access to the SCAAND report, had good knowledge of him and had recognised he was in crisis. Which appears to be in line GMC guidelines here as the prescriber had good knowledge of him to safely proceed and was satisfied the prescription was needed.
31. Mr K attended a further appointment on 3 December with his new CAMHS team at the Trust. It noted he had been assessed at an ARFID clinic the week before and had a further appointment on 18 December. It reviewed his responses to previous medication and assessed his mood. It noted his current medication and considered introducing sertraline. It agreed to consider medication further after his appointment with the ARFID clinic. The ARFID clinic emailed the Trust on 18 December to recommend that a trial of sertraline could be beneficial.
32. The CAMHS team reviewed Mr K again on 7 January and noted he had stopped taking risperidone. It also noted they discussed medication with Mr K and his mother, and it said it would wait for a full report from the AFRID clinic before it considered a prescription for sertraline.
33. The ARFID clinic emailed Mr K’s CAMHS team to confirm it considered it was safe to prescribe him with sertraline on 15 January to manage his condition. The Trust issued Mr K with a prescription for sertraline on 21 January 2025.
34. Our clinical adviser explains even though a clinician from the AFRID clinic had advised a trial of sertraline may have been beneficial, the prescribing doctor has the responsibility to ensure the medication is appropriate, necessary and safe for the patient to take. They say Mr K’s presentation changed between the SCAAND team’s assessment in early June and its final report in late July, as he had lost a significant amount of weight, so there was a lot of information to consider, in making this decision.
35. They went on to explain there was also significant changes in the team caring for him at this time which along with his change in presentation, likely contributed to the time it took to provide the prescription. They say the professionals involved in his care needed time to go through Mr K’s records and meet with him, to provide him with the care he needed which included any potential medications.
36. They also explain a potential side effect of sertraline is reduced appetite and it tends to be less effective when a person is underweight, which Mr K was during this time. They note Mr K had been sensitive to medications he had been prescribed in the past. Overall, they say as Mr K’s clinical presentation and his CAMHS team changed in this time, the caution the CAMHS team expressed with prescribing sertraline was warranted until it received a specialist’s approval.
37. Based on the information we have seen, it appears the Trust followed GMC guidelines when it waited until January 2025 to be satisfied sertraline was an appropriate medication to prescribe Mr K with. We can see it took time to review his records, assess his presentation and response to medications. We can also see it got specialist advice to ensure it was safe for him to be prescribed sertraline based on his AFRID diagnosis and recent weight loss. It also considered the effectiveness of the medication when a person is underweight, and the impact it can have on appetite.
38. It is clear from what Miss C told us, that she feels the delay with the Trust providing Mr K with a prescription for sertraline led to his symptoms worsening and he was admitted to the Trust due his low weight. It is understandable this led to the distress Miss C told us she experienced, which we are sorry to hear about.
39. We are satisfied the Trust did not get anything wrong and followed guidance when it waited to prescribe Mr K with sertraline. We will therefore not take further action on this complaint.
40. We do not underestimate how difficult it must have been for them to relive these events and explain their complaint to us. We are grateful for the time and effort they have taken to do this. We hope that the information we have provided to explain what the Trust did and why this is in line with the relevant guidelines helps her to further understand what happened.
Referral 41. They also complain about its decision to decline his referral to its EDS in August 2024. They say this contributed to him being admitted to the Trust with acute food refusal. Miss C says she had to battle for services for Mr K, at an already distressing time, which we are sorry to hear about.
42. It is important to explain we cannot see evidence in Mr K records that the Trust’s EDS team received any referrals in August 2024.
43. Mr K’s records show the SCAAND team assessed him June. It emailed the Trust on 5 July with a summary of its findings and recommended the Trust consider referring him to its local ARFID pathway. ARFID is an eating disorder where someone avoids certain foods, limits how much they eat or both.
44. It is important to note the Trust’s EDS team did not have commissioned ARFID pathway at the time of events. There are no national guidelines which say the Trust should have an ARFID pathway. Therefore, we cannot say it has not followed guidelines by not having one in place.
45. We can see the Trust completed a referral to it EDS team on 17 July and it triaged it the following day. It noted Mr K’s referral showed high risk factors which indicated the need for an urgent assessment, therefore accepted the referral. It planned to call his parents to discuss any changes in circumstances.
46. It attempted to call Miss C on 26 July but there was no answer. It discussed Mr K with Miss C on 31 July. It explained its service does not have treatment to offer for ARFID and it agreed with her that it would discuss Mr K with other parties involved in his care to decide what would be helpful for him.
47. Based on the evidence we have seen, there is no indication the Trust declined Mr K’s referral to its EDS in July, or August as Miss C told us. It is understandable that Miss C is frustrated the Trust do not offer specific treatment for ARFID. We can see from the Trust’s response it explains there is not a specific pathway in Gloucestershire that is linked to a clear evidence base. However, it says it can offer intensive clinical management, which is effective for some young people with ARFID, and it recognises that commissioning work needs to take place across the whole network.
48. Based on what we have seen we cannot see the Trust’s EDS team declined a referral for Mr K in July or August as suggested by Miss C. There is evidence which shows the Trust accepted the referral and planned to assess Mr K. Therefore, we have seen no indication that the Trust got anything wrong. We will therefore not take further action on this complaint.
49. We understand Mr K’s experience has caused them both great distress and we are sorry to hear about this. We hope this statement clearly explains our decision not to consider their complaint further and gives them some reassurance the Trust has taken their complaint seriously.