Quetiapine
14.Mr C is unhappy the Trust prescribed him the anti-psychotic, quetiapine, and says the Trust staff did not listen to his concerns about the medication. Mr C explained he researched the medication and found it is primarily used to treat psychosis and conditions such as schizophrenia or bipolar, which he did not have. The Trust had diagnosed Mr C with emotionally unstable personality disorder (EUPD) and depressive episode.
15.Mr C explained he started to suffer side effects from the quetiapine, including hallucinations, body rushes and sweats. He added the events caused him significant distress and upset. We are sorry to hear how these events have impacted Mr C.
16.In the complaint response, the Trust explained that following a medical care plan review in January 2022, the psychiatrist considered that quetiapine would be the most useful drug for Mr C, given he had previously tried a range of anti-depressant medications which did not work for him. The Trust explained that quetiapine was prescribed for its antidepressant properties and mood stabilising effects, as the psychiatrist concluded this would be beneficial to Mr C.
17.The Trust explained that when Mr C raised concerns about quetiapine with his duty worker, the psychiatrist was informed about this and completed medication reviews. The evidence shows the Trust tried different dosages and also prescribed an alternative slow-release form of quetiapine because the psychiatrist thought it would help ease the side effects Mr C was suffering.
18.The relevant NICE BNF guidance lists the clinical indications for quetiapine as:
•schizophrenia •treatment of mania in bipolar disorder •treatment of depression in bipolar disorder •prevention of mania in depression and bipolar disorder •adjunctive treatment of major depression.
19.Our adviser explained quetiapine can be used in clinical practice as an antidepressant and is frequently used for individuals with more difficult to treat depression that has not responded to an adequate trial of various antidepressant medications.
20.Prior to the events complained about, the Trust had diagnosed Mr C with depressive episode. Mr C had tried several different antidepressant medications and was of the view none of them worked for him. There are multiple entries within the medical records where Mr C confirmed he was not willing to introduce an antidepressant medication. Our adviser explained quetiapine is an effective medication for treating depressive disorder and tends to be initiated when a patient has not achieved optimal clinical response from antidepressant therapy alone.
21.Given that quetiapine can be used to treat depression as per the above guidance, and Mr C had already tried multiple antidepressants, we consider the prescription of quetiapine to be in line with guidance. Our adviser said that the use of quetiapine in this case was clinically indicated and justified.
22.The dose of the initial prescription of quetiapine commenced in January 2022 was 25mg. The psychiatrist told Mr C the medication would be commenced at a low dose to ensure he would not be over sedated.
23.Over the following months, the Trust increased Mr C’s dose of quetiapine to the following:
•50mg in early February •75mg in late February •100mg in early March •125mg in late March •150mg in late April.
24.Our adviser confirmed the dose increases of Mr C’s quetiapine were in line with safe prescribing practice. Our adviser explained Mr C’s prescribed dose was always within the maximum daily dose.
25.We understand that Mr C is unhappy and feels his concerns about quetiapine were not being listened to. There is a note in the records from April 2022 where Mr C explained to his duty worker that he felt the quetiapine was not helping and that he always feels lethargic and had gained weight. The outcome of this concern being raised was the Trust switching Mr C to a slow-release form of the medication. The records confirm Mr C was happy to continue with the slow-release quetiapine.
26.In May 2022, Mr C raised further concerns with his duty worker in relation to the quetiapine. The evidence shows the duty worker asked the psychiatrist to review the medication in light of Mr C’s concerns. Following a review, the psychiatrist reverted Mr C back to plain quetiapine to try and help him, and ease his side effects.
27.In June 2024, Mr C had a consultation with his psychiatrist. During this consultation Mr C raised concerns about the quetiapine, said he felt it was not helping him, and thought the medication had done the opposite of what it was intended to do. The psychiatrist told Mr C he should stop the medication and provided him with a reduction regime. Mr C’s dose of quetiapine was reduced to 50mg daily for a few days, then to 25mg daily before coming off the medication completely. By early July, Mr C was completely off quetiapine
28.Our adviser explained the Trust’s actions in relation to taking Mr C off the quetiapine were entirely appropriate and conducted promptly after Mr C’s consultation with the psychiatrist.
29.When Mr C did raise concerns in relation to quetiapine, whether that be to his duty worker or his psychiatrist, the Trust took action. The evidence shows the Trust tried different forms of the medication to try and ease Mr C’s symptoms and took him off the medication all together after he raised additional concerns. We find the actions of the Trust here to be correct.
30.We understand the importance of Mr C’s complaint, and we thank him for giving us the opportunity to look at it. In summary, we have found that the Trust appropriately prescribed Mr C with quetiapine in line with guidance. We have also found the Trust appropriately carried out medication reviews and took Mr C off quetiapine after he raised concerns about this medication. We are sorry if this decision causes any further distress to Mr C.
Acamprosate
31.Mr C is unhappy with the contents of the letter the Trust sent him outlining his discharge from the service.
32.In the Trust’s letter to Mr C, it explained it would be important for him to take prescribed medication such as acamprosate if he was to be re-referred to the service. Mr C says this made him feel like he would need to take medications just for the sake of compliance. He added that this being given as part of the rationale for his discharge caused him significant distress. We are sorry to hear how these events had an impact on Mr C.
33.Acamprosate is a medication which is used in the maintenance of abstinence in alcohol dependent patients. We understand that it was not the Trust who prescribed Mr C with acamprosate. Turning Point (a drug and alcohol treatment charity) referred Mr C to a rehabilitation centre in 2020 where he was started on acamprosate.
34.In its response to his complaint, the Trust explained that the comments it made in relation to it being important Mr C takes acamprosate, was a general point about the need for Mr C to adhere to agreed care plans to bring about lasting and positive change.
35.The Trust said that if a service user has any concerns over a medication, they can be raised with the prescribing doctor who can consider changes if the service user feels their medication is not benefiting them.
36.There is a note in the medical records where Mr C informed his duty worker that he had been told he would ‘need’ to take acamprosate to ‘prove’ his engagement and abstinence from alcohol. We don’t know exactly what was said regarding acamprosate, but Mr C was clearly left with the impression he needed to take this medication to prove his engagement with the service.
37.Whilst the Trust highlighted the importance of Mr C sticking to agreed care plans, this was not the main reason for his discharge. The Trust explained that it considered Mr C could only be actively helped to address his mental health problems through a combination of treatments. It explained this would involve medication, key worker input for coping strategies, and possible background psychological support. The Trust explained that its service was not set up to offer that level of intense input.
38.The NHS Constitution sets out what responsibilities patients have in contributing to their own good health and wellbeing. It asks patients to follow the course of treatment they have agreed to and talk to their clinician if they find this difficult.
39.Our principles of good administration say:
‘Public bodies should give people information and, if appropriate, advice that is clear, accurate, complete, relevant and timely.’
‘Public bodies should be open and truthful when accounting for their decisions and actions. They should state their criteria for decision making and give reasons for their decisions.’
40.Ultimately, we accept the Trust’s comments about acamprosate caused Mr C some distress and added to his concerns about the Trust telling him to take it in the first place. However, we do not consider the actions of the Trust regarding this amount to maladministration.
41.The Trust has explained what it meant by its comments in the letter it sent to Mr C, and we consider its explanation to be reasonable and in line with our principles of good administration. They also reflect the advice set out in the NHS Constitution. The Trust also said if a service user does have concerns over a specific medication, it could carry out a review of that medication. There is evidence the Trust already did this with a different medication (quetiapine) when Mr C was under its care.
42.In summary, we are sorry to learn how the Trust’s comments regarding acamprosate medication caused Mr C distress, and we acknowledge the time of the events was a difficult experience for Mr C. We consider the comments the Trust made regarding acamprosate to be reasonable in explaining the importance of a patient sticking to treatment plans. We have therefore found no failings for this complaint, and we are sorry if our decision causes Mr C any further distress.