Lancashire and South Cumbria NHS Foundation Trust

5. Mr H complains about aspects of the care and treatment he received from Lancashire and South Cumbria Foundation NHS Trust (the Trust), between September 2023 and November 2024. Specifically, he says:

• in January and August 2024, the Trust reviewed his EUPD diagnosis and inaccurately maintained this diagnosis. Mr H says the consultants overlooked his complex mental health needs and failed to consider alternative diagnoses such as complex post-traumatic stress disorder (C-PTSD) or bipolar

• in two multidisciplinary team (MDT) meetings held in 2024, the Trust said that medication for EUPD is ineffective and did not provide him with medication. Mr H says that he challenged this view, but the Trust ignored him

• following his diagnosis review in August 2024, the Trust failed to make arrangements to prescribe him lithium and aripiprazole, and instead said the GP should prescribe this

• between September 2023 and November 2024, the Trust failed to provide him with community mental health support and failed to provide him a caseworker.

6. Mr H says the incorrect diagnosis of EUPD led to his discharge from mental health services, a lack of appropriate treatment for his condition, and a lack of the appropriate community mental health support. He says this left him feeling suicidal and he started self-medicating with ketamine and cannabis.

7. He says the Trust’s poor treatment of his condition negatively impacted his treatment for fibromyalgia and left him at a greater risk of developing hypermania. He says his fibromyalgia consultant, described the anti-depressants he had been using for his fibromyalgia as ‘dangerous’ due to its potential to trigger hypermania and mania in people with bipolar. Mr H says the consultant told him that if he had been prescribed mood stabilisers for his mental health, it would have enabled him to safely explore more treatment options for his fibromyalgia as those would have eliminated the hypermania and mania.

8. Mr H says he has experienced significant distress and has missed out of life opportunities such as starting education and employment. He says his overall mental health has been negatively impacted and he feels let down. When he did not receive a mood stabiliser, after the consultant told him one would be trialled, this caused him confusion, distress and frustration.

9. By bringing this complaint to us, Mr H is seeking a financial remedy and service improvements.

10. Since 2015 Mr H has had a diagnosis of EUPD. This is a personality disorder which can cause intense and fluctuating emotions.

11. On 12 September 2023, Mr H requested CMHT support and underwent an assessment. The Trust declined him CMHT support, stating he did not meet the criteria. It suggested Mr H could benefit from a psychiatric review as he did not agree with his EUPD diagnosis.

12. On 5 October and 27 November 2023 Mr H was referred to the initial response service (IRS). This is a mental health support service that provides support to those experiencing mental health concerns. The CMHT team made the first referral and his GP made the second.

13. On 4 January 2024, a psychiatrist re-assessed Mr H and confirmed a diagnosis of EUPD. They also considered Mr H possibly had complex post-traumatic stress disorder (C-PTSD). This is a mental health condition that arises from ongoing, inescapable relational trauma.

14. On 21 June, Mr H’s GP requested a further review of Mr H’s diagnosis and referred him to the IRS. The Trust declined this diagnosis review or to offer Mr H CMHT support. Mr H submitted two separate complaints to the Trust about these decisions in July 2024. Following this, the Trust agreed to refer Mr H to a different consultant for a second opinion of his diagnosis.

15. On 30 July, Mr H self-referred to the IRS.

16. On 8 August, the second consultant confirmed EUPD, signs of C-PTSD, and suspected cyclothymia. Cyclothymia is a mild form of bipolar disorder, which causes mood changes from feeling low to emotional highs. They recommended trialling lithium and aripiprazole (mood stabilisers).

17. On 4 September, Mr H contacted the IRS to discuss who would initiate the medication. The IRS attempted to contact his GP about this but was unsuccessful.

18. On 10 September, the Trust considered Mr H’s CMHT eligibility and his need for a caseworker. It denied both and asked Mr H’s GP, to consult an IRS doctor via the advice and guidance portal regarding prescribing Mr H with a mood stabiliser.

19. On 16 October, the GP referred Mr H to the IRS again, as they were not comfortable in initiating and managing the mood stabiliser medication. The GP requested CMHT support.

20. On 29 October the Trust declined Mr H CMHT support and said it would not prescribe him a mood stabiliser. The Trust told the GP again to use the advice and guidance portal to consult a psychiatrist.

21. Mr H submitted a complaint to the Trust on 8 November 2024, due to him not receiving a mood stabiliser. The Trust responded on 27 November 2024.

Diagnosis in January and August 2024

25. Mr H complains that following his diagnosis reviews in January and August 2024, the Trust inaccurately maintained his diagnosis of EUPD. He also says during these assessments, the consultants overlooked his complex mental health needs and failed to consider alternative diagnoses such as C-PTSD or bipolar (a mental health condition where you have extreme mood changes).

26. We have reviewed the clinic letters from these assessments, dated 24 January and 9 August 2024. We have also reviewed the Trust’s final complaint response, dated 27 November 2024. In the clinic letter from January, the consultant said Mr H clearly met the criteria for the diagnosis of EUPD and he may have C-PTSD, but this needed further corroboration. They said there was no evidence to support a diagnosis of bipolar.

27. In the clinic letter from August, the consultant explained the symptoms of bipolar, EUPD, attention deficit hyperactivity disorder (ADHD), autistic spectrum disorder (ASD) and post-traumatic stress disorder (PTSD) can overlap. They say this can make it difficult to diagnose patients, particularly when a patient is misusing substances.

28. We know from what Mr H has told us and from his clinical records, he was using substances including cannabis and ketamine and has a diagnosis of ASD and ADHD. The consultant said Mr H showed traits of EUPD and agreed to maintaining this diagnosis. They also considered Mr H possibly had C-PTSD and suspected cyclothymia.

29. We asked our adviser whether the Trust’s decisions to maintain Mr H’s EUPD diagnosis in January and August 2024 were in line with clinical standards and guidance, considering his presentation, symptoms and history.

30. Our adviser explained Mr H’s diagnosis of EUPD is consistent with international diagnostic criteria (ICD) 10 and 11. This is because Mr H’s symptoms included long term mood instability, suicidal ideas and actions, unstable relationships, impulsivity in relationships, long-term trust issues and substance abuse. These symptoms are consistent with those listed in these diagnostic criteria and information published on MIND (a mental health charity), regarding borderline personality disorders.

31. Our adviser explained in ICD 11 (the guidelines in place from 2022), the term used for Mr H’s diagnosis is personality disorder mild, moderate or severe, with borderline qualifier. Once the diagnosis of a personality disorder is established, consultants then describe the level of severity mild, moderate and severe. In ICD 10 (which was in place at the time of Mr H’s original diagnosis), the terminology was EUPD.

32. We asked our adviser if the Trust was correct to continue using the ICD 10 terminology and not change to the updated ICD 11 terminology. Our adviser says both EUPD and personality disorder (mild, moderate or severe) with borderline qualifier cover the same territory. As Mr H has a diagnosis of EUPD since 2015, it would not have added any benefit changing to the new ICD 11 terminology, as this would not have changed his care and treatment. Our adviser explained when there is a long-standing diagnosis which has not changed, it is not helpful to change the terminology as it can have a negative effect or cause the patient confusion. This is because if a consultant says a patient is anything other than severe, this is likely to make the patient feel invalidated.

33. There is evidence in the clinic letters that both consultants kept an open mind and did consider alternative diagnoses such as C-PTSD or bipolar in January and August 2024. Our adviser says based on the clinical records Mr H’s symptoms did not match bipolar disorder. This is because the symptoms expected from bipolar disorder are mood episodes that last for quite a long time, months to years in some cases. This would also include periods of being completely stable, high mood and low mood, which are not triggered by incidents.

34. Our adviser said some of Mr H’s symptoms matched those associated with ASD, C-PTSD and ADHD. Our adviser explained that diagnosing C-PTSD alongside diagnoses such as ASD and ADHD can be difficult due to overlapping symptoms. They said consultants should take an openminded, practical approach. ICD 11 describes the core symptoms of C-PTSD as avoiding uncomfortable thoughts, feelings, and sensations and hypervigilance (heightened state of sensory sensitivity and alertness). Our adviser explained for a diagnosis of C-PTSD, these would need to be present and in Mr H’s case, the records from that time do not document any of these core symptoms.

35. We are sorry to hear Mr H does not agree with his diagnosis of EUPD and feels consultants did not consider his complex needs and consider alternative diagnoses. We must base our decisions on the evidence available to us. The evidence shows Mr H’s symptoms in January and August 2024 were consistent with a diagnosis of EUPD. We recognise the terminology between ICD 10 and ICD 11 has changed. We consider the Trust acted reasonably by maintaining the term EUPD, given Mr H had a diagnosis of EUPD since 2015 and there was no change to his presentation which would have changed his care and treatment. Additionally, we recognise changing the term may have caused Mr H confusion.

36. We consider the consultants did keep an open mind and consider alternative diagnoses of C-PTSD and bipolar, as they documented their considerations in the clinic letters. The evidence we have seen indicates the consultants made reasonable clinical decisions that Mr H’s symptoms were not in line with bipolar disorder. We recognise he did show some symptoms that are consistent with C-PTSD. We consider the consultants did keep an open mind and explored the potential for a diagnosis of C-PTSD or bipolar. As such, we do not consider there to be any indications something went wrong, and we will not be considering this part of the complaint further.

The Trust said medication for EUPD is ineffective and did not provide Mr H medication

37. Mr H says in two multidisciplinary team (MDT) meetings in 2024, the Trust said it would not provide him medication for his EUPD diagnosis as it is ineffective. We are sorry to hear Mr H felt the Trust ignored him and would not provide him with medication.

38. The Trust has provided us with Mr H’s clinical records, which include all MDT meetings which discussed Mr H’s care and treatment in 2024. We cannot see any evidence the Trust say it will not prescribe him medication because it is ineffective. The MDT notes from 29 October say the Trust will not be prescribing Mr H lithium (a mood stabiliser drug) as it is not indicated (not recommended).

39. NICE guideline 78 says patients should not usually be offered medication to specifically treat a borderline personality disorder (such as EUPD), or any related symptoms or behaviour (such as self-harm, unstable moods and risky behaviour). If consultants consider medication could help someone in crisis, they can prescribe medication for no longer than one week. NICE guidelines 78 and 116 say the main treatment for both EUPD and C-PTSD is psychological treatment options.

40. Our adviser explained long term medication has not been found to be effective for EUPD, unlike psychological treatment. If a consultant decided to follow NICE guidelines 78 and prescribe medication for short term use, it would done on an unlicenced basis as it falls outside the standard prescribing guidelines. This is because there is no specific medication used for EUPD. GMC prescribing guidance says the decision to prescribe medication for off-licence use is the sole responsibility of the prescriber. The prescriber must deem it appropriate and believe that the potential benefits outweigh any risks. This must be clearly justified and is subject to audit, as it is not standard treatment.

41. Our adviser noted the records show Mr H previously reported adverse effects to some medication. Additionally, Mr H told consultants he was misusing substances. Therefore, there are prescribing challenges and risks that the prescriber would need to carefully consider, especially when prescribing medication off licence. The records also show Mr H was engaging with cognitive behavioural therapy (CBT – a type of psychological treatment) in June 2024 and he was finding this helpful.

42. We did not see any evidence from the records the Trust said medication is ineffective. We know the Trust MDT said it is not recommended therefore, it would not prescribe this to Mr H. On review of the evidence, we cannot see any indications that this is a failing. This is because the guidelines say there is no specific medication for EUPD, and the treatment is psychological therapy. Our adviser confirmed any decision to prescribe medication off-licence is the prescriber’s decision. We consider the prescriber choosing not to prescribe to Mr H was not against guidelines. As such, we will not be considering this part of the complaint further.

Did not provide CMHT support and a caseworker between September 2023 and November 2024

43. Mr H says the Trust failed to provide him with CMHT support and a caseworker between September 2023 and November 2024. In Trust’s responses it says the CMHT considered Mr H did not meet its eligibility criteria for CMHT support.

44. We have reviewed Mr H’s clinical records for this time. The records show throughout this time, Mr H did not agree with his EUPD diagnosis and requested multiple diagnosis reviews, believing he has bipolar. The records say the Trust previously offered Mr H dialectical behaviour therapy (DBT), a talking therapy, but he declined this as he did not agree with his diagnosis. The records also state the Trust began offering Mr H CMHT support from November 2024.

45. From the records, we can see Mr H was raising continuous concerns with the Trust during this time regarding his diagnosis, as he believed it was wrong. He also brought concerns regarding his housing, unhealthy relationships and substance abuse.

46. The records show Mr H was receiving input from various services during this period, including the crisis team, substance misuse support via Inspire, social services who were helping him with his housing, and input from an autism specialist service. The Trust also conducted two diagnosis reviews, in January and August 2024.

47. The Trust’s CMHT policy says the eligibility for CMHT support is for people with a severe mental health disorder. The policy also says the Trust can provide CMHT support to people who suffer with mild and moderate mental health disorder, if attempts with primary care have failed. For personality disorders, the policy notes that those requiring skilled or intensive treatments within secondary care (such as DBT) may be eligible.

48. There is minimal information in the records about the Trust’s considerations when it declined Mr H CMHT support. We asked the Trust to provide us with any further information regarding its considerations. We also asked it what changed for the Trust to start providing Mr H CMHT support in November 2024.

49. The Trust told us each time it reviewed Mr H’s eligibility it did so with a full MDT and medical consultation. The Trust acknowledged there is limited information documented in the MDT’s specific considerations in Mr H’s records. The Trust told us it has taken learning from this and will feedback to the CMHT that it should document its decisions for accepting or not accepting referrals in meetings in more detail.

50. The Trust says there was no change in clinical presentation that led to the decision to give Mr H CMHT support in November 2024. The Trust said the records indicate that due to the number of referrals into the service and discussions with IRS, the CMHT agreed to support Mr H for a period of monitoring and review.

51. We asked our clinical adviser if the Trust acted in line with its policy when it declined Mr H CMHT support and a caseworker between September 2023 and November 2024. Our adviser noted the records show Mr H had significant concerns during this time relating to his EUPD diagnosis. They also recognised Mr H’s issues with substance misuse, housing and unhealthy relationships. Our adviser says when there is complexity like this, there is a reasonable argument that a period of CMHT involvement may have been warranted, if attempts at primary care have failed. They also say Mr H would be eligible for CMHT services to support with intensive psychological therapies, such as DBT.

52. From the records, we know Mr H did not want to engage with DBT, as he did not agree with his EUPD diagnosis. We consider the Trust acted reasonably, exploring these concerns by reviewing Mr H’s diagnosis on two occasions. After these diagnosis reviews, Mr H is still of the opinion he does not have the correct diagnosis.

53. The records state the Trust signposted Mr H to ASD counselling support. It also states he was accessing support from other primary care services such as drug and alcohol support and his social worker to help with his housing issues.

54. We are sorry to hear Mr H believed he should have received support from the CMHT earlier. On review of the Trust’s CMHT eligibility within its Community Mental Health Team CMHT Procedure policies (v 2.2, v.3 and v.4), we consider it is reasonable the Trust allowed a period of time for Mr H to engage with these specialist services at primary care, before reviewing his eligibility and offering him CMHT support and a caseworker. The criteria refer to people where an initial phase of care has been delivered without recognised improvement, and ongoing specialist care and treatment is required. The criteria also refer to people who have had a poor response to previous mental health treatment in primary care.

55. When accessing the primary care services alone did not help Mr H, we consider the Trust acted appropriately by reconsidering his CMHT eligibility in November 2024 and offering him support. Therefore, we have not seen any indications of a failing and will not be taking any further action on this part of the complaint.

Failed to arrange mood stabiliser prescription and asked the GP to do this

56. Following Mr H’s diagnosis review in August 2024, the consultant suggested trialling Mr H on a mood stabiliser, such as lithium or aripiprazole. Following this review, the Trust did not arrange this prescription, and instead said Mr H’s GP should prescribe this.

57. From the records, we understand Mr H’s GP told the Trust they were not comfortable starting this prescription and asked the Trust to start this. The Trust directed the GP to the advice and guidance portal, which allows GPs to speak with a consultant about medication.

58. In the Trust’s response dated 27 November 2024, it acknowledges it did not follow Trust policy by asking the GP to prescribe this medication or use the portal. It explained its policy says the CMHT should initiate medication, such as lithium and aripiprazole, then monitor the patient for three months, after which the GP would take over prescribing responsibility. It says as the Trust made the recommendation to trial a mood stabiliser, it was the Trust’s responsibility to act on those recommendations. The Trust apologised to Mr H in its response. We know from the clinical records the Trust has now started prescribing Mr H with a mood stabiliser.

59. Our clinical adviser confirmed the Trust holds responsibility for any prescribing decision and it was not suitable for the GP to initiate treatment with a mood stabiliser. However, our adviser explained the Trust’s decision not to prescribe Mr H with lithium or aripiprazole was in line with NICE guidelines 78 and 116, and GMC prescribing guidance. This is because the decision to prescribe off-licence medication is solely down to the prescriber’s professional judgement, after they have weighed up the risk vs the benefits. As referred to above, Mr H had a history of adverse reactions to some drugs, which increased the risk of starting any new medication. Additionally, the NICE guidelines say prescribing medication can be for short term crisis, for no longer than one week. Information on the NHS website says both lithium and aripiprazole can take several weeks to work.

60. We are sorry to hear Mr H feels he has been unable to start employment or university without a mood stabiliser. We recognise the consultant suggested trialling Mr H on a mood stabiliser in August 2024. It must have been very disappointing for Mr H when this did not happen. Based on the above guidelines the Trust was under no obligation to fulfil this prescription if the prescriber did not consider it was appropriate. Therefore, there is no indication of a failing in the Trust’s decision not to prescribe Mr H with a mood stabiliser, and we will not be considering this further.

61. We recognise the Trust did not follow its policy when it asked the GP to prescribe the mood stabiliser. It was not suitable for the GP to do this as these medications should be initiated by the Trust, in line with the policy. Because of the Trust’s request to Mr H’s GP, it is reasonable to say Mr H expected he would receive a mood stabiliser from his GP. When this did not happen, we recognise this caused him confusion, distress and frustration.

62. We should consider closing a complaint through resolution where we are able to achieve a satisfactory result for the complainant. Our aim is to make the right decision at the right time. Our principles of remedy state remedies should be fair, reasonable and proportionate to the injustice or hardship suffered.

63. As the Trust acknowledged in its final response letter it did not follow its policy, we contacted it on 8 December explaining our initial assessment of the case. We shared with the Trust the impact Mr H said the Trust’s miscommunication had on his mental health and the outcomes he sought by bringing his complaint to us.

64. We recognise the Trust has taken action to improve its service following Mr H’s complaint. The Trust has discussed the matter with the staff involved and shared learning for the wider team through the clinical leads. We are satisfied these actions should reduce the likelihood of these issues occurring again.

65. We asked the Trust to consider Mr H’s outstanding outcome of a financial remedy. In a response dated 19 December, the Trust told us it has acknowledged the impact its miscommunication regarding prescribing Mr H a mood stabiliser had on him. The Trust said it will make a payment of £500 to recognise this.

66. Our severity of injustice scale helps us decide an appropriate amount of financial remedy, depending on the injustice the person has suffered. Importantly, our scale explains in cases where a person has experienced emotional distress lasting longer than one – two weeks but less than six months we usually recommend a financial remedy between £120 to £550. We recognise Mr H suffered a period of emotional distress from the Trust’s miscommunication. We consider it is reasonable to say this impact lasted longer than two weeks but less than six months.

67. We consider the Trust’s acknowledgement and apology in November 2024 will have provided Mr H with some reassurance and relief that it had recognised it should not have asked his GP to prescribe the mood stabiliser. The Trust has told us Mr H has had a further assessment with a consultant in February 2025, during which he discussed the consultant prescribing him a mood stabiliser again. Although the outcome was not to prescribe and to continue with CMHT support, we consider Mr H’s earlier impact of confusion, distress and frustration from the Trust’s miscommunication will have been resolved through this further discussion.

68. The Trust has acknowledged and apologised for not following policy and has taken learning from Mr H’s complaint. It has now offered a financial remedy, which is in line with our severity of injustice scale for the distress Mr H told us about. This is in line with all the outcomes Mr H wants by bringing his complaint to us.

69. We are satisfied the Trust has now taken (or agreed to take) appropriate action to resolve this part of Mr H’s complaint. Therefore, we will not be taking any further action.

70. We would like to thank Mr H for bringing his complaint to us.

1. We have carefully considered Mr H’s complaint about Lancashire and South Cumbria NHS Foundation Trust (the Trust). We are very sorry to hear Mr H believes the Trust inaccurately maintained his diagnosis of emotionally unstable personality disorder (EUPD) and overlooked other diagnoses. We are also sorry to hear he believes the Trust should have provided him with community mental health team (CMHT) support, a caseworker and a mood stabiliser. We understand from what he has told us this has caused him to feel confused, let down and that he has missed out on life opportunities such as going to university.

2. We want to reassure Mr H that we did not see any indications of failings in the Trust’s decision to maintain his diagnosis of EUPD and its consideration of other diagnoses. We also saw no indications that something went wrong when the Trust did not provide him with CMHT support and a caseworker between September 2023 and November 2024. We explain the reasons for this further in this statement.

3. We have also considered Mr H’s complaints regarding the Trust not prescribing him a mood stabiliser and asking his GP to do this. We want to reassure Mr H we saw no indications something went wrong when the Trust did not prescribe him a mood stabiliser. However, we understand the Trust should not have asked the GP to do this. The Trust has acknowledged this in its final complaint response, apologised and says it has spoken with the clinicians involved and wider clinical team to help prevent similar occurrences in the future.

4. The Trust has now offered to make a financial remedy of £500 to remedy the impact its miscommunication about the prescribing caused Mr H. We have decided the Trust has now done enough to put right the impact therefore, we will not be considering this complaint further. We explain the reasons for our decision below.