Delay in preliminary health checks
16. The law (The Health Service Commissioners’ Act 1993) says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Mr A to understand the reasons why he could not do so. We have also considered the time the organisation has taken to respond to him.
17. Mr A says the Trust took a total of 19 weeks to complete the preliminary health checks to enable clinicians to prescribe quetiapine.
18. Clinical records show Mrs A had the first appointment with the Trust on 18 April 2023. During the assessment the clinician noted ‘impression cyclothymic mood disorder’ and noted the plan was to review Mrs A’s medication at the upcoming multi-disciplinary team (MDT) meeting. The medication review was planned to consider mood stabiliser medication.
19. It is noted in the records, Mrs A was looking to stabilise her mood with medication as the medication she was on at the time did not work for her.
20. On 27 April 2023, during the MDT meeting clinicians agreed Mrs A needed another appointment as the Trust could not issue GP shared care plan only on the basis of the assessment made in the assessment team.
21. The Trust booked a further appointment on 11 May 2023. This was attended by Mr and Mrs A. The Trust offered quetiapine and a backup medication but to be prescribed after a physical health check.
22. Physical health check appointment booked for 29 August 2023. It was attended by both Mrs and Mr A.
23. We note Mr A complains about events that took place between 11 May and 29 August 2023.
24. As Mr A complaints the Trust took a vey long amount of the to undertake the preliminary health checks to enable it to prescribe quetiapine, we are of the view Mr A had reasons to complaint between 11 May and 29 August 2023 or shortly after 29 April 2023.
25. The Health Service Commissioners’ Act 1993 (the law) states members of the public should refer their complaint to us within one year of when they became aware of the problem they are complaining about.
26. Having considered the facts of this complaint it is our view Mr A should have referred this aspect of the complaint to us no later than 23 August 2024.
27. Mr A referred this aspect of the complaint to us on 22 January 2025.
28. The law gives us the Ombudsman the discretion to set aside the 12 months’ time limit if it considered reasonable to do so.
29. We contacted Mr A to understand the reasons why there was a delay.
30. Mr A explained it is his view the overall treatment his ‘wife received from the Trust was atrocious and there was a catalogue of failings’. Mr A explained he could urge us to consider the entirety of the complaint as this will evidence the Trust’s failings.
31. Based on medical records we see Mrs A was keen to try new medication as soon as possible. We recognise the wait for the prescription must have been distressing especially as she was waiting to return to work.
32. Based on the evident Mr A provided we found no sufficient reason to set aside the time limit therefore we will not take any further action in respect to this part of the complaint.
Cancelled appointments
33. Mr A says the Trust cancelled a series of appointments between 24 October and 10 November 2023 and this has delayed further the access to quetiapine.
34. Records show, Mrs and Mr A attended the physical health check appointment booked for 29 August 2023.
35. Next appointment was scheduled for 24 October 2023 (consultant review). The Trust rescheduled this appointment for 1 November 2023.
36. Medical records show the Trust also reschedule the appointment dated 1 November 2023 and rescheduled for 2 November 2023. Lastly, the Trust had to reschedule the appointment dated 2 November 2023 to 10 November 2023.
37. Complaint records show Mrs A complained to the Trust about this aspect at the end of October 2023.
38. At the time, the Trust explained the cancellations were due to consultant availability and the outcome of this complaint was the appointment dated 10 November 2023 when Mrs A received the quetiapine prescription.
39. Following this appointment, Mr and Mrs A did not complain further to the Trust.
40. Mr A explains to us that he remains dissatisfied with this aspect of the complaint because the Trust said the cancellation was due to the nominated consultant not returning from leave and is difficult for them to accept this as truly unforeseen. Mr A also explains he has asked the Trust to transfer his wife’s care to a different consultant but was told the team was waiting for a new doctor to join them.
41. We recognise the delayed appointments led to distress and anxiety. We can see this was a difficult time as Mrs R wanted to start quetiapine as soon as possible. We acknowledge is difficult to learn about NHS staff shortages and recognise these have a real impact on patients.
42. As discussed, the law states members of the public should refer their complaint to us within one year of when they became aware of the problem they are complaining about.
43. Having considered the facts of this complaint it is our view Mr A should have referred this aspect of the complaint to us no later than 10 November 2024.
44. Mr A referred this aspect of the complaint to us on 22 January 2025.
45. The law gives us the Ombudsman the discretion to set aside the 12 months’ time limit if it considered reasonable to do so.
46. We contacted Mr A to understand the reasons why there was a delay.
47. Mr A explained it is his view the overall treatment his ‘wife received from the Trust was atrocious and there was a catalogue of failings’. Mr A explained he could urge us to consider the entirety of the complaint as this will evidence the Trust’s failings.
48. Based on the evident Mr A provided we found no sufficient reason to set aside the time limit therefore we will not take any further action in respect to this part of the complaint.
Medication review
49. To decide if we should conduct a detailed investigation into a complaint, we first consider whether there are any indications something went wrong with the service provided by the organisation. If so, we then explore if the organisation would be willing to take further steps to put this right and resolve the complaint.
50. Mr A complaints the Trust did not undertake a medication review following the quetiapine prescription.
51. Medical records show the Trust recommended Quetiapine, on 10 November 2023. Records detail at the time of this appointment Mrs A’s care plan includes the following points: • follow-up in two months, however it was explained to the patient that she can be seen earlier if her symptoms persist • Mrs A will be reviewed by the pharmacy technician every two weeks when she arrives or her repeat prescription.
52. There is no record that the pharmacy technician reviews took place. Mrs A had an initial review appointment on 8 March 2025. This appointment was later brought forward to 22 February 2024. However, it did not take place as Mrs A cancelled the appointment the day before. The appointment was rebooked for a date in June 2024. Again Mrs A called to advise that she would be unavailable for the date in June 2024 and requested that it be rescheduled. The Trust discharged Mrs A discharged middle of September 2024 without any review taking place.
53. NICE [CG185] covers recognising, assessing and treating bipolar disorder in children, young people and adults. The recommendations apply to bipolar I, bipolar II, mixed affective and rapid cycling disorders. It aims to improve access to treatment and quality of life in people with bipolar disorder. This guideline is relevant to this case because the Trust prescribed quetiapine to enable Mrs A to address some of the symptoms related to bipolar disease.
54. NICE [CG185] recommends ‘the secondary care team should maintain responsibility for monitoring the efficacy and tolerability of antipsychotic medication for at least the first 12 months or until the person's condition has stabilised, whichever is longer. Thereafter, the responsibility for this monitoring may be transferred to primary care under shared-care arrangements’.
55. Our adviser reviewed Mrs A’s medical records and confirmed Mrs A should have been reviewed to assess the efficacity and tolerability of the antipsychotic medication.
56. We are pleased to see the Trust made a plan to review Mrs A’s by the pharmacy technician every two weeks when she collected her prescription. Sadly, there is no note in the medical records this occurred. Mr and Mrs A gave us a detailed account that this did not happen.
57. We have more evidence to conclude on the balance of probabilities the Trust did review Mrs Bodey every two weeks when she was collecting her prescription.
58. We are also pleased the Trust’s plan included a follow-up appointment two months after quetiapine started. Sadly, we have seen the review did not took place.
59. As such, we have seen indications the Trust did not review Mrs A’s medication in line with NICE [CG185].
60. We are sorry to hear Mrs A and her family experienced distress and anxiety due to this.
61. During this process, we approached the Trust and asked if it would be willing take further action to put this complaint right. The Trust agreed to this. Therefore, we have decided not to take any further action.
62. We provide further details about this at paragraphs 75 and 76 of this report.
Discharge
63. To decide if we should conduct a detailed investigation into a complaint, we first consider whether there are any indications something went wrong with the service provided by the organisation. If so, we then explore if the organisation would be willing to take further steps to put this right and resolve the complaint.
64. Mr A says the Trust discharged his wife from its care without a review and without notice.
65. Medical records detail the Trust made a shared care agreement request, at the end of January 2024, to Mrs A’s GP and the GP accepted this request. A shared care agreement is a formal arrangement between an NHS hospital specialist and a GP, allowing care to be safely shared between both services. It is used when a patient starts a specialist medicine or treatment in hospital that may need ongoing prescriptions or monitoring from their GP.
66. Medical records also document the Trust discharged Mrs A, by letter, without a prior conversation, in September 2024.
67. NICE [CG136] covers the components of a good experience of service use. It aims to make sure that all adults using NHS mental health services have the best possible experience of care. This guideline is relevant to this case as Mrs A was under the care of NHS mental health services.
68. NICE [CG136] relates to service user experience in adult mental health. The following sections are relevant: 1.7.1 Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people using mental health services. Ensure that: such changes, especially discharge, are discussed and planned carefully beforehand with the service user and are structured and phased the care plan supports effective collaboration with social care and other care providers during endings and transitions, and includes details of how to access services in times of crisis when referring a service user for an assessment in other services (including for psychological treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them.
1.7.2 Agree discharge plans with the service user and include contingency plans in the event of problems arising after discharge. Ensure that a 24 hour helpline is available to service users so that they can discuss any problems arising after discharge.
1.7.4 Give service users clear information about all possible support options available to them after discharge or transfer of care.
69. In this case, there are indications, the Trust discharged Mrs A without any consultation with the patient. In keeping with NICE [CG136] efforts should have been made to have a discussion with the patient about discharge in advance of the decision being made. In this case, we recognise Mrs A cancelled two appointments prior to her discharge. We are mindful, on both occasions she had informed the service prior to the appointment and had requested that they be rescheduled.
70. Moreover, we recognise the shared care agreement might have a bearing on this discharge. We note the Trust has an approved share care agreement protocol. Medical records show Mrs A’s shared care request Trust does not follow the template as described in the Trust’s protocol. Specifically, in the case of Mrs A there are no details that indicate when the GP should undertake the monitoring and what type of monitoring should be undertaken in line with NICE [CG185] and it is not noted when the Trust would review next Mrs A.
71. We also recognise the Trust’s view is that it has discharge Mrs A in line with transformation of community mental health services policy. We have seen indications this discharge was not in line with not in line with NICE [CG185] and NICE [CG136]. Namely, the transfer of care did not provide clear instructions to the GP in line with NICE[CG185] and the discharge was not planned beforehand with the service user.
72. We recognise the discharge letter generated anxiety and distress as Mrs A was not aware of the Trust’s plans of discharge. We are sorry to hear she did not have the opportunity to explore the option of managing her symptoms without quetiapine. There is no evidence Mrs A was distressed about the lack of monitoring until the Trust discharged her. As such, we recognise Mrs A lost confidence in the Trust after discharge, and she was distressed. Based on the evidence Mrs A provided we have not seen any indications the emotional distress led to a degree of functional impairment.
73. During this process, we approached the Trust and asked if it would be willing take further action to put this complaint right. The Trust agreed to this, as in the case of the third component of this complaint.
74. Our NHS Complaints Standards (2023) say organisations should find ‘suitable and appropriate ways to put things right for people who raise a complaint’.
75. In this case, the Trust is willing to offer a letter of apology and a summary of current work to improve discharge arrangements from its community mental health services. The Trust is also willing to pay £200 to remedy the distress Mrs A experienced. We consider these actions in line with our NHS Complaints Standards will remedy the complaint. Therefore, we have decided not to take any further action.
76. Complaints give us valuable insight into the organisations we investigate, and we recognise this has been an emotionally challenging process for Mr and Mrs A. We would like to thank Mr and Mrs A for sharing her experience with us.