Complaint about the assessment and consideration of depression
13. Mr and Mrs R are concerned Dr C concluded their son was not depressed. The records show Dr C has documented ‘he is not anxious nor depressed but still struggles with lack of motivation.’
14. It appears Dr C may have been documenting what Mr S told her. However, on this we cannot be certain. We do know that Mr S had a diagnosis of longstanding depression and in the treatment plan put in place on 22 May, Dr C referenced the NICE guidance. This is the guidance specifically for treating and managing adults with depression. We also know they increased Mr S’s dose of anti-depressant.
15. Dr C was treating Mr S for depression and therefore we have not found a failing in diagnosis.
16. Mr and Mrs R say Dr C did not fully consider their son’s history or that he was suicidal when assessing and deciding how to treat him.
17. The NICE guidance says doctors should conduct a comprehensive initial assessment when assessing a person who may have depression, which takes account of severity of symptoms, previous history, duration and course of illness. They should discuss with the person how several listed factors may may have affected the course and severity of their depression.
18. The description of depressive episodes in WHO ICD-11 includes symptoms such as difficulty concentrating, feelings of worthlessness, excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide.
19. Our adviser said when assessing the extent of depression, there are a lot of symptoms to consider. They said mood disorder presentations can fluctuate, both day to day and with variations throughout the day. Other negative emotions may be experienced, such as hopelessness, helplessness or worthlessness.
20. Our adviser said it is necessary to consider all these factors to ensure there is a comprehensive assessment of condition and presentation, to then formulate the appropriate plan for treatment.
21. In Dr C’s statement to the coroner and the Trust’s comments to us, they said that prior to the consultation, Dr C reviewed Mr S’ medical records on the Trust’s computer system. We agree that doing so was necessary and appropriate.
22. However, in line with the guidance, these factors should still have been explored with Mr S on 22 May, as this was his initial assessment with a psychiatrist since being referred to the service.
23. We know that there was discussion about Mr S’s lack of motivation. However, we have not seen evidence that there was exploration of any other negative symptoms Mr S may have been experiencing or whether his symptoms fluctuate.
24. We have seen that Dr C discussed factors such as previous psychological treatments, his relationship with his ex-wife and daughter, and employment situation. However, we have not seen any evidence from the records, Dr C’s statement to the coroner, or the Trust’s comments to us that Dr C discussed several factors with Mr S. This included his previous depressive history including his previous suicide attempts, the duration and course of his illness, including what had led to him being assessed at that time.
25. We have seen no evidence within those documents that they discussed his living conditions and alcohol use, any difficult relationships, or traumatic life events.
26. We know from the previous records that some of those things were relevant to Mr S. Therefore, we would expect to see evidence of what was discussed and how they were considered.
27. We do not dispute that Dr C assessed Mr S on 22 May. However, considering the evidence we have seen, we are not persuaded that this was sufficiently comprehensive. It was not in line with the NICE guidance and is a failing.
28. Turning to the assessment of risk, the NICE guidance says risk assessment and management are part of an assessment. Doctors should ask people directly about suicidal ideation and intent. If there is a risk of self-harm or suicide, the doctor should assess whether the person has adequate social support and is aware of sources of help, arrange help appropriate to the level of need, and advise the person to seek further help if the situation deteriorates. They should advise the person and their family about mood changes and behaviours to be aware of.
29. A systemic review explains that previous suicide attempts are a significant factor associated with suicide. Mr S had previously (in 2020) had a very serious suicide attempt which resulted in a lengthy hospital admission, including a period in intensive care. His GP had referred him to the Trust in 2023 due to anxiety and suicidal thoughts and attempts at the end of 2022.
30. NICE NG225 describes risk formulation as a ‘collaborative process between the person and mental health professional that aims to summarise the person’s current risk and difficulties, understand why they are happening to inform a treatment plan. It typically includes taking into consideration historical factors and experiences, more recent problems, and existing strengths and resources.
31. It defines safety plan as ‘a written, prioritised list of coping strategies and/or sources of support that the person can use to help alleviate a crisis. Components can include recognising warning signs, listing coping strategies, involving friends and family members, contacting mental health services and limiting access to self-harm methods.’
32. Our adviser said part of the risk assessment is learning from the previous suicide attempts, understanding the circumstances that led to it, what happened, how the person was presenting in the lead up and what the triggers may have been. A comprehensive risk assessment would involve considering what treatment options had been trialled in the past and what had been effective for him, particularly in the time after his suicide attempts. It should identify risk factors and what can be changed or mitigated for.
33. In the record of 22 May, the only entry directly relevant to assessment of Mr S’s risk is that he does not have thoughts of harm to himself or others. Dr C repeated this in her statement to the coroner.
34. In comments to us, the Trust said Dr C considered Mr S’s historical risk information and incorporated it into the clinical formulation and treatment plan. It said Dr C discussed Mr S with their clinical supervisor. However, in her statement to the coroner, Dr C said there was no indication for further discussion with their consultant.
35. In her statement to the coroner, Mrs R says her son told Dr C he was suicidal. There is clearly a conflicting account between Mrs R and Dr C of what was said here. Although we are unable to reconcile this, it does not prevent us from reaching a view about the risk assessment.
36. As set out above, we know Mr S had very serious attempts at self-harm. Only a few months prior to the assessment, he had again attempted to take his own life. It was this and the ongoing thoughts which led to him being assessed on 22 May.
37. We have not seen any evidence in the records, statements or comments that this was explored further with Mr S during the consultation. We have not seen any evidence that Dr C discussed with Mr S factors detailed in paragraph 30. We have not seen any evidence of a safety plan in line with the guidance referred to at paragraph 31.
38. Although we can see there was some consideration of Mr S’s risk, on balance the evidence we have seen does not persuade us this was comprehensive. This was not in line with what should happen as set out above and is a failing.
Impact of this failing
39. As set out above, Dr C’s assessment of Mr S did not comprehensively consider his depression and factors which may be contributing to it. However, we can see that in addition to an increase in medication (which we considered further later in the report), Dr C suggested psychological therapies and discussed alternative approaches such as physical activity and, when he was ready, referral to the employment agency.
40. Our adviser said these were all appropriate actions. We can see that they are treatment options set out in the NICE guidance.
41. We cannot say that if Dr C had completed a more comprehensive assessment, this would have led to any other treatment being proposed.
42. Turning to the risk assessment, our adviser said if this had been completed comprehensively, it would provide a more robust understanding of when Mr S would be at greater risk and what can be done to support him at those times. It would consider what had been trialled in the past, and what had previously been effective for him, in the time after suicide attempts.
43. The aim of any mitigations put in place are to try to keep the patient safe. They do not entirely remove the risk. Our adviser said they cannot say that if a comprehensive assessment and risk assessment had been done, it would have had any positive impact on Mr S’s state of mind.
44. As such, have not found that if the failings in the assessment had not happened, this would have prevented Mr S’s very sad death. However, it would have provided reassurance to his parents that everything possible had been done to try to reduce the risk of this happening.
45. This lack of reassurance is an emotional injustice to Mr and Mrs R when they are grieving for their son.
Complaint about the increased dose of sertraline
46. The NICE guidance explains antidepressant medication is a recommended treatment option for depression. It says selective serotonins reuptake inhibitors (SSRIs), which are a type of antidepressant, are well tolerated and should be considered as the first choice for most people. It says they should usually be taken for at least six months.
47. Sertraline is a type of SSRI. The Formulary explains the starting dose of sertraline is 50mg a day. This can then be increased in steps of 50mg at intervals of at least a week if required, up to a maximum of 200mg a day.
48. The NICE guidance sets out the further line treatment where there has been no response to antidepressant treatment after several weeks. One of these options is to increase the dose of the same antidepressant if it is well tolerated.
49. At the time of the assessment, Mr S was taking 100mg sertraline per day. His GP prescribed this in January.
50. Mr and Mrs R say their son was experiencing lack of motivation and blunting or dulling of his emotions due to sertraline. There is evidence in the records Mr S had previously stopped taking sertraline as he felt it gave him emotional blunting. He had started taking it again in February 2023 and whilst he reported his anxiety was less, he was feeling no pleasure from any activities.
51. The Formulary explains the potential side effects for sertraline, and for SSRIs more broadly. It lists the common, uncommon and rare side effects. Blunting or dulling of emotions is not listed as a side effect.
52. There is some evidence from a research paper that patients report that they have less emotional pain with SSRIs than they had during their depressive episode. However, nearly half of patients who are taking or have taken various classes of antidepressants report experience a restriction in the range of emotions they associate with normal living, such as the ability to cry or feel enjoyment. This is defined as emotional blunting.
53. The paper says it is unclear whether the reason for this is a side effect of the treatment or a residual symptom of depression. The NHS website explains having no motivation or interest in things and not getting any enjoyment out of life are psychological symptoms of depression. Therefore, we cannot say sertraline was the cause of Mr S’s symptoms.
54. Overall, it appeared Mr S tolerated sertraline well, with no clear side effects from it. The increase to 150mg of sertraline, which is not the maximum dose, was in line with the Formulary and NICE guidance. As such, we have not found a failing.
Complaint about bupropion medication
55. In the UK bupropion is only licensed as a medication to help people stop smoking. Any use of bupropion for another condition outside the terms of its UK licence would be considered ‘off-label’.
56. The Trust policy says its doctors should not start patients on bupropion. It is not listed in the Trusts formulary (a list of medication the Trust prescribes).
57. National guidelines show medications can be prescribed if they are unlicenced, depending on the circumstances. GMC prescribing guidance says unlicensed medications are commonly used in some areas of medicine such as psychiatry.
58. It says doctors may prescribe unlicensed medicines where, based on an assessment of the individual patient, they conclude for medical reasons it is necessary to do so to meet the specific needs of the patient.
59. GMC guidance says doctors must recognise a patient’s right to choose whether to accept their advice, and respect their right to seek a second opinion. They should consult colleagues where appropriate and refer a patient to another suitably qualified practitioner when this serves their needs.
60. The NICE guidance says if a person with depression wants to try a combination treatment and is willing to accept the possibility of an increased side-effect burden, consider referral to a specialist mental health setting or consulting a specialist.
61. The BAP guidelines explain that where there is partial or insufficient response on the current antidepressant, doctors can consider adding other medications. One of these they can consider is bupropion.
62. On 22 May, Mr S asked Dr C to prescribe bupropion to him. He had done some research and believed it could boost the dopamine levels in his brain which can help to increase motivation.
63. Dr C told Mr S doctors mainly prescribe this to help in smoking cessation. They said it has positives and negatives, one of the negatives being it supresses appetite which Dr C said was an issue for Mr S as he is not eating well and had reported losing weight.
64. We can see that in Dr C’s view, they did not consider bupropion was a suitable medication for Mr S. The Trust policy and GMC prescribing guidance, set out above, means there was no obligation on Dr C to prescribe this medication. It was a matter for their clinical judgement.
65. We consider the doctor’s decision not to prescribe bupropion at that time was in line with the Trust policy and GMC prescribing guidance.
66. Instead, Dr C increased the dose of sertraline, which we have considered in the section above. In her statement to the coroner and comments to us, Dr C says to her understanding Mr S and his mother agreed with this plan. In her statement, Mrs R says they did not explicitly agree to this.
67. Mrs R described that as they were about to leave the consultation room, her son kept the door ajar with his foot and asked Dr C if she would prescribe bupropion next time. We find her description of this compelling and we are satisfied this request by Mr S indicates that he still wanted to try bupropion, even if at a future point.
68. Mr S was already taking two anti-depressant medications and was requesting a medication which was not licenced for that use. We know from the BAP guidelines there is evidence that bupropion can be used as an alternative treatment. Our adviser said this is from a collective body of clinicians and cannot be ignored.
69. As Mr S indicated he still wanted to try bupropion even after Dr C had discussed this with him and declined to prescribe it, this should have been explored further.
70. The BAP guidelines say management of the more unusual or complex medication regimes may best be undertaken in liaison with specialist service or clinicians with a specialist interest.
71. We understand there are various services which provide for specialist assessment of complex or unusual cases. Our adviser said these services will initiate and monitor medications that do not fit into the routines of prescribing, as they have the experience to do so.
72. We appreciate approaching such services may not be a first step, due to the need to apply for funding. There may be internal processes which could have been taken initially to ensure Mr S’s continued request for a more unusual prescription could be considered, perhaps by senior staff or referral through drugs and therapeutic committees.
73. We have set out in paragraphs 64 and 65 that we do not criticise Dr C for declining to prescribe bupropion on 22 May. However, as Mr S indicated he still wanted to try bupropion even after Dr C had discussed this with him and declined to prescribe it, arrangements should have been made for this to be explored further. In our view, this would have been in line with the GMC guidance, GMC prescribing guidance and NICE guidance.
Impact of the failing
74. If Dr C had sought specialist input or a second opinion for Mr S, we do not know when he would have been reviewed. Our adviser said it is not possible to say whether, following specialist input, doctors would have prescribed bupropion to him at some point in the future. They said it is a decision which would have been influenced by what other therapeutic interventions had been tried.
75. We acknowledge that in May 2023 there were supply issues with bupropion in the UK, although these appear to have resolved by the end of that year. We can see that it is therefore very unlikely bupropion would have been prescribed to Mr S during 2023, even if Dr C had sought further input.
76. We recognise Mr and Mrs R say the refusal to prescribe bupropion with no suggestion of possible future provision left their son without hope. Even if bupropion had been prescribed at some point after the appointment on 22 May, there is no specific evidence it would have been effective in preventing Mr S’s suicide.
77. We know from the systemic review that Mr S had factors which are significantly associated with suicide. We also do not know what happened in the days from 22 May to 2 June, and what may have affected Mr S’s state of mind during that time. Therefore, we cannot say Mr S’s tragic death on 2 June would not have happened if this failing had not occurred.
78. However, we recognise the failing had an emotional impact on Mr S. Knowing this, and that he later died by suicide, has left his parents with uncertainty around how this failing may have affected their son’s state of mind. This uncertainty is an injustice to them.