Dosage and monitoring of sertraline
13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Practice has done enough to put right the impact of these events.
14. Mr J told us he was put on too slow a titration of sertraline. He believes this caused him to have suicidal thoughts and worry that he could not keep himself safe.
15. The GMC (2021/2) guidelines for ‘Good Practice in prescribing and managing medicines and devices’ explains prescribers are responsible for their decisions and actions, and the steps they take to make sure that prescriptions are appropriate, necessary and safe.
16. In its response to Mr J’s complaint, the Practice acknowledge the dose prescribed was lower and slower than recommended, but that it is not unreasonable to do this if there is concern about side effects. The Practice does not mention it was concerned about specific side effects in Mr J’s case, however. It goes on to say, “the GMC Duties of a Doctor requires that doctors ‘take account’ of relevant guidelines, not that they are slavishly followed as a ‘one-size-fits-all’ approach to every individual situation’.
17. In its review of Mr J’s complaint with the Practice, the ICB reported BNF Guidelines for sertraline recommend a starting dose of 25mg once daily for social anxiety for one week, then increase to 50mg once daily, then increased in steps of 50mg at intervals of at least one week if required. The guidelines recommend increasing only if the patient partially responds and if the drug is tolerated. The recommended maximum dose is 200mg per day. The titration of sertraline prescribed by the Practice was not in line with this guidance.
18. NICE Guidelines advises close monitoring for patients within Mr J’s age range who are started on sertraline. It recommends initial review after one week for suicide risk and weekly until there is no increased suicide risk, then every two to four weeks during the first three months of treatment. It recommends patients should then be monitored each month. More generally, NICE advises regular review for patients diagnosed with social anxiety, ideally face-to-face or using their preferred method of communication.
19. In June 2024, the Practice prescribed 25mg of sertraline for social phobia to be taken every other day for two weeks, then 25mg daily. One month later the Practice followed up with Mr J via text to see how he was getting on. Mr J replied to say he had not noticed any side effects. The Practice replied it would be in touch with Mr J again in September 2024.
20. In August, Mr J requested another sertraline prescription, which the Practice reissued the same morning.
21. The next day, Mr J requested a change of GP which was accepted by the Practice and effected in late August. However, his original GP had already set for another text message to be sent to him in early September asking how Mr J was finding the sertraline and what dose he was up to. Mr J replied he had yet to notice any benefit at 50mg daily after almost three weeks at that dose. The GP replied to suggest increasing the dose to 75mg daily for three weeks, and then up to 100mg if Mr J did not see any difference.
22. In mid-September Mr J submitted an eConsult to the Practice stating he was experiencing mild stomach ache on the 75mg dose, and still not noticing any reduction in the anxiety he felt. Mr J indicated through his answers to the online questions he had not had thoughts of suicide or self-harm, or of hurting someone else. The Practice booked him an appointment to see the new GP two weeks later.
23. At the appointment, the GP noted Mr J was not responding to sertraline and advised weaning off it with a view to review in four weeks to consider an alternative treatment.
24. By late September 2024, Mr J started to experience suicidal thoughts and contacted 111 and spoke to an out-of-hours GP. The GP advised him to go to his local hospital emergency department to be seen by the hospital Liaison Psychiatry team (LP team).
25. The LP team wrote to the Practice stating it had discussed the possible benefit of a change in Mr J’s antidepressant medication to optimise it to a therapeutic dose for depression, or to consider changing the antidepressant medication to an alternative. The team asked the Practice to consider prescribing Mr J 15mg of mirtazapine and to stop sertraline. It also asked the Practice to consider referring Mr J to its Specialist Mental Health worker.
26. The Practice arranged for an appointment with Mr J’s previous GP who noted what had initially been more of a social phobia/anxiety presentation had changed to one more of depression. The GP advised to continue weaning off sertraline and starting Mirtazapine 15mg and prescribed this. The Practice also arranged for an appointment with a Specialist Mental Health worker attached to the practice six days later.
27. The Practice followed up with Mr J via text one month after first prescribing sertraline and then again just over one month later via text. This is not in line with guidance. The Practice did not address this specifically in its response to Mr J.
28. After PHSO contacted the Practice in August 2025 about Mr J’s complaint, it offered to meet with Mr J to discuss his complaint further. Following this meeting, the Practice wrote Mr J a letter apologising for not prescribing and monitoring sertraline in line with guidance. It states it will review any existing policies it has relating to the initiation and monitoring of anti-depressants. It will either remind clinicians of these if they are already in line with guidance or will write new policies to bring them in line with guidance. The response acknowledged the standard of care Mr J received from the Practice was not always to an acceptable standard and expressed sincere regret for this.
29. We have considered whether the apologies, explanations and improvements the Practice has made are enough to address the impact Mr J experienced. Mr J potentially experienced additional distress from not having increased levels of sertraline in the timeframe set out in the Guidance. We consider the impact on Mr J matches level 2 of our Severity of Injustice scale, as the potential impact was short in duration and he was not left without treatment completely, during that time.
30. The NHS Complaint Standards say where an organisation identifies things have gone wrong it should find an appropriate remedy to put things right. The NHS Complaint Standards say organisations should look to remedy the impact on the complainant and look for wider opportunities to share wider learning.
31. The Practice has shared its learning with the prescribing GP and wider team and said it will review its policies around the prescription and monitoring of antidepressants. The Practice apologised to Mr J for the impact its mistakes had on him. We are satisfied the Practice has appropriately addressed the complaint and worked to prevent similar incidents in future. For these reasons, we feel it has done enough to put this aspect of the complaint right.
Autism assessment referral
32. Mr J says during an appointment in March 2024, a GP asked him if he had considered he may be neurodivergent. Mr J told the GP he had but was engaged with another organisation at the time having therapy and wanted to complete that before pursuing a diagnosis.
33. Mr J told us he felt the Practice should have pursued an autism diagnosis for him after the GP made this suggestion as it would have sped up the process.
34. In response to Mr J’s complaint, the Practice state Mr J said he did not want to pursue a diagnosis at the time and so the Practice was adhering to Mr J’s preference.
35. The Autism Guidance says an autism assessment should be considered where certain circumstances or experiences are present in a person’s life. It also states staff who have responsibility for the identification or assessment of autistic adults should adapt the procedures set out in guidance, if necessary, to ensure their effective delivery. In this case, the GP discussed suspected neurodivergence and adhered to Mr J’s preference for waiting to pursue a diagnosis.
36. We think it is reasonable the Practice did not pursue an autism diagnosis based on Mr J’s preference at that time. We have seen no indication of failings for this part of the complaint.
37. We can see the Practice showed knowledge of autism when it suggested the possibility of underlying neurodivergence with Mr J.
38. When Mr J confirmed he was being supported elsewhere, did not consider himself neurodiverse and did not want to pursue a diagnosis at the time, the Practice acted in line with the Autism Guidance by adapting to the patient’s preference.
39. In these circumstances, we think it was reasonable for the Practice not to provide further signposting in relation to autism and do not consider this indicates a lack of knowledge or appropriate signposting. We have seen no indications of failings for this part of the complaint.
40. We thank Mr J for bringing his complaint to us and hope our decision gives some closure to the issues he raised.