15. 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 something has gone wrong.
Medication for paranoia
16. Mr K says matters would not have escalated to the point where is his wife physically harmed herself had the Practice prescribed stronger medication.
17. The Practice says olanzapine which is an antipsychotic medication must be recommended by a psychiatrist first.
18. Mr K says there were plenty of drugs that can be prescribed for paranoia.
19. MIND, which is a mental health charity, explains paranoia is not a mental health problem itself but can be a symptom of psychosis.
20. NICE psychosis guidelines say in managing psychosis in primary care ‘do not start antipsychotic drug treatment while awaiting specialist assessment unless under advice from a consultant psychiatrist.’
21. NICE CKS say, ‘the secondary care team should maintain responsibility for monitoring the person's physical health and the effects of any antipsychotic medication for at least the first 12 months of treatment.’ It says after 12 months the responsibility for monitoring may be transferred to primary care.
22. We asked our adviser whether there was anything else the Practice could have prescribed for paranoia. Our adviser says there was not. They explained as paranoia comes under the category of psychosis, specialist input is required before prescribing medication.
23. We also asked our adviser whether there were any medications the Practice could have prescribed to help Mrs K’s mental health. The records show the Practice had already prescribed antidepressants. Our adviser confirmed there were no other medications the Practice could prescribe without specialist input.
24. We do not underestimate how traumatic it must have been for Mr and Mrs K when she suffered a mental health emergency. NICE guidelines prevented the Practice from prescribing medications outside of the ones Mrs K already had.
25. The only other thing the Practice could have done was refer Mrs K to mental health services for specialist recommendations, which it did. We will discuss this referral in further detail later in our report. We have not seen indications of a failing on this part of the complaint therefore we will not take further action.
Sleep medication
26. Mr K says he asked the GP to prescribe a stronger dose of zopiclone which is a medication to help with sleep. He says the GP refused.
27. Mr K says there was no reason his wife could not have had an increased dose as she had no history of abusing the medication.
28. The Practice said the prescribing of zopiclone comes with risks. In its complaint response it said ‘The Sussex Partner formulary states long term reliance on sleep medication can lead to serious side effects and dependence’ and explained patient safety is its top priority.
29. NICE guidelines explain Z-drugs are licensed for the short-term management of insomnia (difficulty sleeping). Zopiclone is one of these drugs. It says the risk of dependence increases with the dose and duration of treatment. It also says prescribe Z-drugs with caution to people with psychiatric illness including depression as there is a possible increased risk of suicidal ideation or attempts.
30. Adverse psychiatric effects of Z-drugs can include nightmares, agitation, hallucination, impaired cognition and concentration, depression, suicidal ideation and attempt, anxiety, psychosis and behavioural abnormalities, restlessness, irritability, aggression, delusions, anger, and inappropriate behaviour.
31. GMC guidance for good medical practice says propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied the drugs or treatment will meet their needs.
32. There is nothing noted in the medical records of Mr K requesting increased medication. We can appreciate why the GP may have been reluctant to increase Mrs K’s zopiclone given her mental health history and presentation at the time. There was a danger the increased dose could have made things even worse.
33. We consider the Practice acted in line with NICE and GMC guidance. Mrs K was not herself at the time and we can see how increasing her medication may not have been advisable.
34. We appreciate Mr K’s thinking that a good night’s sleep would have been beneficial for Mrs K.
35. We can also see the GP did not refuse sleeping medication completely but prescribed promethazine which is antihistamine medication that can provide sedation.
36. We have not seen indications of a failing and so will not take further action on this part of the complaint.
A&E
37. Mr K explained how his wife’s presentation continued to worsen in A&E when they attended following the GP’s referral. We are sorry to hear Mrs K suffered horrible paranoia and anxiety so much so Mr K could not keep her there and had to go home.
38. Mr K said a doctor had seen them after several hours and was going to refer her to the mental health team but it was too late by then, he could not control her.
39. Mr K says had the GP referred them to see someone in mental health initially, she would have seen someone sooner.
40. Our adviser explained from Mrs K’s presentation it would have been difficult for the GP to know whether the extreme difference in her presentation was due to a mental health problem or a physical one.
41. They said there was nothing more the GP could have done ahead of her A&E attendance without this knowledge.
42. Our adviser explained it would not have been appropriate to refer Mrs K solely with mental health concerns and it was right to explore physical issues first.
43. In the records the GP wrote ‘I think she needs bloods and a scan to rule out a bleed or neoplasm. If tests normal I will request urgent mental health review.’
44. The GP also wrote a letter for Mr and Mrs K to take with them to A&E. The GP wrote Mrs K ‘is absolutely not herself’. They said she was only providing one word answers or nods to questions which was not like her. The GP explained Mrs K had a history of mental health issues and thought she needed scans and blood tests to rule out a bleed or stroke.
45. On the following day, the Practice saw Mrs K had not waited to see the crisis team in A&E. It completed an urgent mental health referral. Our adviser noted the referral was very well detailed.
46. GMC guidance for good medical practice says clinicians must promptly provide (or arrange) suitable advice, investigation or treatment where necessary. It also says refer a patient to another suitably qualified practitioner when this serves their needs.
47. From what we have seen the Practice acted in line with GMC guidance. The Practice provided A&E with information as best as it could. There was no way for it to know the cause of Mrs K’s presentation before she attended A&E but it did inform them of her mental health history.
48. We are sorry to hear how distressed Mrs K was whilst waiting to be seen in A&E. The A&E discharge summary states ‘she was referred to the mental health team but she refused to wait for review and preferred to be seen and referred by her GP’.
49. NHS information on when to attend A&E says all patients are assessed by a doctor or nurse before any treatment takes place. It says A&E departments are very busy and it is likely you will have to wait to be seen.
50. Unfortunately demand and pressures on the service means wait times are unavoidable.
51. We have not seen evidence to suggest the Practice could have done any more than it did. We have not seen indications of a failing.
52. We are pleased to see the Practice continued to support Mr and Mrs K while she waited to be seen after sending the urgent mental health referral.
53. The Practice agreed to see Mrs K at least every week, face to face whilst she waited. Our adviser explained this was above and beyond what would usually be expected. The Practice also provided the triage number for if Mrs K experienced any significant deterioration in her mental health whilst she awaited initial assessment.
54. We appreciate that was an extremely difficult time for Mr and Mrs K. We are sorry to hear how Mr K felt he could not leave Mrs K alone at any time which must have been highly stressful for them.
55. At the time of complaining to us Mr K explained Mrs K was on the correct medications and building her confidence back which we are pleased to hear. We can see Mr K has been and continues to be a huge support for Mrs K.
56. Whilst we have not found indications something went wrong, that is not to say their experience was not traumatic. Our decision is not intended to diminish this in any way.
57. We thank Mr and Mrs K for bringing the complaint and sharing their experiences.