15. Mr L says the Trust inappropriately prescribed him a dangerous concoction of medication including quetiapine, diazepam, temazepam and pregabalin during his appointments on 17 December 2018 and 30 April 2019. He says the medications were not prescribed in line with guidance. He says as a result he suffered multiple side effects including twitching, disturbed sleeping patterns, rocking, memory problems and teeth grinding.
16. On 17 December 2018 Mr L was reviewed in the outpatient clinic and the consultant psychiatrist decided there should be a change to his treatment plan and psychotropic medication. Amitriptyline was stopped and replaced with Mirtazapine, he was also started on Quetiapine. His prescriptions of Diazepam and Temazepam and Pregabalin were continued with adjustments.
17. Prior to this, Mr L had been prescribed Diazepam of 5 mg up to three times daily as required, which Mr L had been taking regularly. The consultant psychiatrist recommended this be reduced to 5 mg twice daily for one week, then to 5 mg once daily for one week, and then be stopped completely.
18. Mr L had been taking the Diazepam on a long-term basis, i.e. for longer than four weeks. The NICE guidance provides recommendations for completing a benzodiazepine withdrawal. This includes a withdrawal schedule for diazepam. The guidance is, for a dose of Diazepam of 40 mg daily or less:
· Reduce by 2–4 mg every 1–2 weeks until dose is 20 mg daily, then · Reduce by 1–2 mg every 1–2 weeks until dose is 10 mg daily, then · Reduce by 1 mg every 1–2 weeks until dose is 5 mg daily, then · Reduce by 0.5–1 mg every 1–2 weeks until completely stopped.
19. We can see the above withdrawal regime was not followed by the Trust’s doctor. This is not in line with the NICE guidance and is an indication of a failing.
20.Our adviser says if Mr L reduced his daily Diazepam dose by 5 mg per week, as recommended by the Trust, it is more probable than not that he would have experienced benzodiazepine withdrawal symptoms as the Diazepam reduction was done too quickly and not cautiously enough.
21.The Maudsley Prescribing Guidelines in Psychiatry list cognitive impairment, impaired memory, insomnia, muscle spasms / cramps, and tremor, as being commonly reported withdrawal effects from benzodiazepines. This could account for some of the twitching, disturbed sleep and memory problems he suffered with at this time.
22. In relation to the stopping of the Amitriptyline and replacing it with Mirtazapine, the Maudsley Prescribing Guidelines recommend that when switching from a tricyclic antidepressant, such as Amitriptyline, to Mirtazapine, the prescriber should ‘cross-taper cautiously’. This means you should cautiously reduce the dose of Mirtazapine. The Maudsley Prescribing Guideline emphasizes the importance of careful consideration of the patient’s condition and the specific medications effects when making such decisions.
23. Mr L’s Amitriptyline was reduced from 100 to 0 mg at night abruptly. Our adviser said Mr L’s Amitriptyline was stopped inappropriately, with it being stopped abruptly rather than tapered down and then stopped, as advised in The Maudsley Prescribing Guidelines.
24.Stopping the Amitriptyline abruptly was not in line with The Maudsley Prescribing Guidelines and is an indication of a failing.
25. Our adviser said it is more probable than not that Mr L will have experienced antidepressant withdrawal symptoms. This is because the sudden stop could lead to a relapse of symptoms, including anxiety and irritability, which are often exacerbated by the discontinuation of antidepressants.
26.However, as mentioned above, as the Amitriptyline was replaced by Mirtazapine which is also an antidepressant, our adviser said this could have helped counteract and lessen the withdrawal symptoms from the Amitriptyline.
27. The most common antidepressant withdrawal symptoms identified, as reported by King’s College London are dizziness, nausea, vertigo, and anxiety. None of these symptoms were reported by Mr L as being any of the multiple side effects that he reported experiencing from the medications he was prescribed following his outpatient medical review on 17 December 2018.
28.Mr L was being prescribed two benzodiazepines – Diazepam and Temazepam, and he was also prescribed Pregabalin 150 mg twice daily.
29.Drugs.com explains that taking Pregabalin and benzodiazepines together is known to ‘increase side effects such as dizziness, drowsiness, confusion, and difficulty concentrating’ and in some people, especially the elderly, the combination may cause ‘impairment in thinking, judgment, and motor coordination’.
30.Therefore, it is also possible that the combination of these three medications did cause some of Mr L’s memory problems during this time.
31.However, even though these medications taken together can cause increased side effects, the BNF for each of these medications do no say that they cannot be prescribed together. Our adviser also said these medications were appropriate to treat his mental health and were clinically indicated. As such, we have not seen any indications of failings with the prescribing of these medications of that time.
32. Mr L was reviewed by the same consultant psychiatrist as an outpatient on 30 April 2019. At the time of that review, Mr L’s mental health diagnoses were listed as personality difficulties of mixed type (paranoid, schizotypal, borderline, obsessive compulsive, and avoidant/dependent traits), symptoms of complex PTSD, recurrent depressive disorder with anxiety symptoms, and harmful use of cannabis.
33. The consultant psychiatrist recommended Mr L increase his dose of Quetiapine to 300 mg at night and 50 mg twice daily, resulting in a total daily dose of 400 mg.
34.The BNF for Quetiapine says as an adjunctive treatment for major depressive disorder the usual dose should be 150–300 mg once daily. Our adviser said Quetiapine was being used as a treatment for depressive disorder in Mr L’s case, as such, Mr L’s daily dose of Quetiapine should not have been increased above 300 mg.
35. Mr L was prescribed 400 mg of Quetiapine daily from 30 April 2019. This is not in line with the BNF and is an indication of a failing.
36. The BNF lists the known side effects associated with Quetiapine. These include ‘sleep disorders’ as a ‘common or very common’ side effect of Quetiapine and ‘sleep apnoea’ (which in theory could lead to disturbed sleep pattern).
37. The BNF does not identify twitching, rocking, memory problems, or teeth grinding as being identified side effects specific to Quetiapine. However, the BNF does state that, for all antipsychotics (i.e. including Quetiapine), ‘movement disorders’ (which could in theory include twitching and / or rocking) is a ‘common or very common’ side effect. Therefore, this could account for some of the twitching, rocking and disturbed sleep he suffered with at this time.
38. Therefore, we have seen an indication of a failing with the Trust’s withdrawal schedule for Mr L’s Diazepam and Amitriptyline on 17 December 2018, and the dosage of the Quetiapine on 30 April 2019. We have seen that this could have led to withdrawal symptoms from both the Diazepam and Amitriptyline, which could have accounted for some of the twitching, disturbed sleep and memory problems he suffered with at this time. The increased dosage of Quetiapine could have caused some sleep problems and movement disorders from April 2019.
39.We cannot see from the records how long Mr L continued to take the increased dose of Quetiapine. However, Mr L says he reduced the medications from April 2024 with help from his new GP when he registered with a new Practice.
40.We also consider the mixture of the Pregabalin and benzodiazepines may have caused some of his memory problems, although we do not consider the prescribing of these was inappropriate.
41.Mr L says he is still currently suffering with the long-term side effects of uncontrollable twitches and loss of his teeth through dry mouth and teeth grinding during this time. He says he also constantly rocks back and forth.
42. We can see from the information Mr L provided that Temazepam is the only one of his previous combinations of psychotropic medications (i.e. Quetiapine, Temazepam, Diazepam, and Pregabalin) that he is still prescribed.
43.Our adviser says it is highly improbable that the inappropriate withdrawal schedule for the Diazepam or Amitriptyline, or the increased dose of Quetiapine are responsible for the multiple adverse effects he continues to experience, particularly given the significant period that has passed since these medications were stopped. Any effects of all these medications that were, or that might have been, experienced by Mr L would not still be occurring to the present day.
44. Mr L says he is still prescribed Temazepam and that he has been reducing the dose of this and that it is almost down to zero. Our adviser says it is possible the multiple adverse effects he reports he is continuing to experience are due to his current benzodiazepine withdrawal.
45.Therefore, we cannot say that the indicated failings are causing his current symptoms, we can only conclude that they may have caused some of the symptoms he was experiencing whilst withdrawing from Diazepam in December 2018 and whilst taking the increased dose of Quetiapine in 2019.
Resolution
46. Mr L would like an apology, service improvements and financial remedy.
47. Our Principles for Remedy say where maladministration or poor service has led to injustice or hardship, public bodies should try to offer remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, financial remedy should compensate them appropriately.
48. Our Principles say an appropriate range of remedies will include: an apology, explanation, and acknowledgement of responsibility, remedial action or financial compensation, or any combination of these.
49. We shared our current thinking with the Trust and asked it if it was willing to apologise to Mr L for the impact caused to him due to the indicated failings we had seen above. We also asked if the Trust would provide reassurances of service improvements. The Trust has agreed to this.
50. Mr L is seeking financial remedy. We asked the Trust to pay him financial remedy of £600 which is the lower end of level 3. The Trust has agreed to award Mr L this financial remedy.
51. Our guidance on financial remedy says;
Level 3 (£600 - £1,200) this would include cases where the injustice would have a moderate impact (for example, in terms of distress, worry, inconvenience) but has lasted for a significant period of time; it may also involve cases where a higher impact injustice has been suffered for a short period. The failings may impact to some extent on the affected person’s ability to live a relatively normal life, for example due to stress, impaired sleep, or high levels of inconvenience or uncertainty. However, once the situation is ceased, the person affected would be able to recover quickly.
52. We think lower end of level 3 of our severity of injustice scale is appropriate. We think it is likely that Mr L suffered with an increase in his symptoms of sleep and memory problems, and movements disorders whilst he was withdrawing from Diazepam and whilst he was taking the increased amount of Quetiapine. Whilst we cannot say for how long this was, level 3 covers a significant period of time.
53.However, we cannot say that his symptoms were solely caused by this, as he is still suffering with some of these symptoms years after these indicated failings occurred. We can also see it has caused Mr L distress thinking that his symptoms were being caused by inappropriately prescribed medication.
54. We consider the Trust has agreed to provide an appropriate resolution, in line with Our Principles of Remedy, to resolve the injustice we have found. As such, we will take no further action on Mr L’s complaint. We are sorry to hear about the distressing experience Mr L had at the Trust. Complaints give us a valuable insight into the organisations we investigate, so we would like to thank Mr L for sharing his experience with us.