The Trust did not follow guidelines when assessing and diagnosing (as opiate dependency based) the reason for her headaches,
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 that something has gone wrong.
16. The BASH and NICE guidance say on headaches:
‘All medications used to treat an acute headache can result in medication overuse headaches. Triptans, opioids and combination analgesics are likely to result in development of medication overuse headaches (MOH) more rapidly (treatment taken on 10 days or more per month) as compared to simple analgesics such as paracetamol (treatment taken on 15 days or more per month)’.
17. BASH also says that the ‘Majority of patients improve on withdrawal of the overused medication’.
18. GMP says doctors must provide a good standard of practice and care. If they assess, diagnose or treat patients, they must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient
• promptly provide or arrange suitable advice, investigations or treatment where necessary.’
19. GMP also says, ‘In providing clinical care you must provide effective treatments based on the best available evidence’.
20. Our adviser said the Trust reasoning and diagnosis in January 2024 was in line with the BASH guidance above. Though Ms A says she was taking co-codamol for only eight days (and below the BASH threshold given above) our adviser said this is not a fixed threshold and will vary from patient to patient.
21. The Trust followed an investigation and diagnosis process according to GMP and was attempting to identify the underlying cause for Mrs A’s headaches.
22. Our adviser said co-codamol is known and widely accepted as a possible cause for overuse headaches, and this is reflected in the NICE guidance. They said migraines cannot be treated without stopping co-codamol as it will continue to counteract any other medication prescribed.
23. It was reasonable for the Trust to consider this as a cause for Mrs A’s headaches and to ask her to stop using it for a period until it was entirely out of her system.
24. The Trust acted in line with BASH, NICE and GMP guidance in assessing and diagnosing co-codamol as a possible cause for Ms A’s headaches. It was reasonable for it to ask she stop taking it for a period. For these reasons we will take no further action here.
25. We were reassured to see the Trust provide Ms A a second clinical opinion. This is what Ms A wanted. The second clinical opinion corroborated the findings of the first.
26. We know Ms A felt the Trust was saying she was opiate dependent and that this was on her medical record. We were reassured to see the Trust provide an explanation to Ms A (saying the word dependent was used in a medical sense) and provide a letter to her GP confirming it was not saying she was opiate dependent.
The Trust did not offer a medication review or safe alternative to NSAIDs or co-codamol.
27. There is no standard or guidance to say a medication review should be conducted by secondary care.
28. The Trust did write to Ms A’s GP with a management plan. A review can be conducted in primary care.
29. NICE CKS advises ‘to stop overused medication(s) abruptly for at least 1 month, depending on the drug class, and counselling that headache may worsen initially and there may be other initial withdrawal symptoms’.
30. Our adviser said it would not be suitable for the Trust to prescribe an alternative pain relief whilst it is asking Ms A to stop taking co-codamol for a period. They said any other medication would only be managing the symptoms of Ms A’s headaches and would not be helpful in identifying the underlying cause for the headaches.
31. Ms A could continue to take paracetamol and ibuprofen during this time. The Trust had not told Ms A to stop taking all forms of pain relief.
32. We have evidence of the Trust considering causes for Ms A’s headaches and seeking further medical opinion - specifically sleeping issues.
33. Our adviser said poor sleep is also a well-known and accepted as a possible cause for persistent ongoing headaches. The Trust provided advice around sleep management. This is good practice and what we would expect to see here and in line with GMP guidance at the start of the previous section.
34. The Trust did prescribe mirtazapine to Ms A for other symptoms she told it about her (anxiety/depression) with a beneficial potential side effect of drowsiness, because Ms A was complaining of sleeping issues (which could be a possible cause for her headaches).
35. Our adviser said mirtazapine is an appropriate choice of drug for that.
36. We are satisfied the Trust have demonstrated taking a considered and stepwise approach in working to identify the underlying cause for Ms A’s ongoing symptoms and headaches in line with GMP guidance at the start of the previous section and it did prescribe Ms A medication to help with her symptoms.
37. We have no guidance to say a medication review should have been conducted. We are satisfied the Trust should not have prescribed an alternative to co-codamol.
38. We hope Ms A is reassured the Trust’s actions and management plan was necessary in helping it identify the possible underlying causes for headaches. Even if stopping co-codamol for six weeks (as the Trust recommended) did not help Ms A the Trust could then exclude this as a possible cause. Ms A would not have been without access to other forms of over counter pain relief during any period she was not taking co-codamol.