Issue one - outcome of The Provider’s assessment
14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the Provider 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 the Provider did not follow the appropriate guidance when carrying out Ms R’s assessment and reaching a decision on diagnosis.
15. It is important to note that our role is to consider if the Provider followed the correct process when reaching this decision, and whether it acted fairly. Where a decision has been reached following the appropriate process without fault, we cannot question the professional judgement of a clinician solely because there is disagreement with the decision itself.
16. Ms R complains the Provider did not diagnose her with ADHD and complains that the doctor was influenced too much by her past medical history. Specifically, Ms R says the doctor told her she had some ADHD characteristics, but that she did not meet the criteria because she had a stroke in 2013 and some memory loss.
17. When investigating Ms R’s complaint the Provider observed Ms R’s assessment. It explained its view that the assessment was thorough, covered all appropriate areas and was well thought out and considered. The Provider apologised it was unable to offer her the outcome she wished, but explained the trauma elements of Ms R’s history, as well as her stroke in 2013 and previous care under the memory clinic do hold significance.
18. To consider this part of the complaint, we have reviewed Ms R’s medical records with our adviser. We have also considered the following guidelines:
19. NICE G87, which explains that a diagnosis of ADHD should be made on the basis of:
• a full clinical and psychosocial assessment of the person; this should include discussion about behaviour and symptoms in the different domains and settings of the person's everyday life and • a full developmental and psychiatric history and • observer reports and assessment of the person's mental state. (1.3.1) 20. Similarly, the RCP and BAP guidelines support the principles of: • Careful differential diagnosis • Particular caution where brain injury, stroke, or trauma are present • Recognition of symptoms overlap with anxiety, PTSD and neurological impairment
21. The guidance we have set out above states that clinicians must carry out a careful differential diagnosis when assessing ADHD. This means they must identify and narrow down the possible causes of a patient’s symptoms. This is particularly important where symptoms may overlap with anxiety, post-traumatic stress disorder or neurological injury.
22. The guidance also says clinicians should take full account of a patient’s medical and psychiatric history when deciding whether symptoms are attributable to ADHD or another cause.
23. The records show that Ms R has a history of trauma and a stroke in 2013. They also show ongoing anxiety and neurological symptoms. We understand these conditions can affect attention, memory and emotional regulation.
24. In keeping with this, Ms R reported problems with her memory, concentration, and organisation. She also described difficulties following conversations and completing tasks. The guidance recognises that these symptoms can occur after stroke or trauma and may mimic ADHD.
25. The evidence we have considered highlighted that Ms R’s memory problems developed after her stroke and our adviser confirmed that many symptoms commonly associated with ADHD, including restlessness, agitation and distractibility, may also arise from anxiety or post-traumatic stress disorder. This indicates that Ms R’s presentation was complex, and we can see the clinicians took this into consideration.
26. The records also show the clinicians reviewed Ms R’s developmental history, current symptoms and mental state. The clinicians carefully considered how Ms R’s stroke and trauma could explain her reported difficulties before reaching a decision on diagnosis. We consider this approach was consistent with the guidance referenced above.
27. Given Ms R’s complex presentation, the clinician concluded that whilst Ms R met four out of five criteria for a diagnosis of ADHD, it was possible another mental disorder could better explain her symptoms. The clinician therefore recommended Ms R’s GP referred her on for further assessment with a psychologist to explore this further.
28. Overall, we consider there are indications the Provider acted in line with guidance when carrying out Ms R’s assessment. This is because it appropriately considered all relevant medical, neurological and psychological factors when assessing Ms R and reaching a decision on diagnosis.
Issue two – second assessment
29. Ms R was unhappy with the outcome of her assessment and spoke with a manager at the Provider to complain. Ms R was told to re-send her list of symptoms to the manager, to seek a second opinion. Ms R says she was told that the Provider would not re-assess her as another doctor agreed with the initial doctor’s decision.
30. In response to the complaint, the Provider says it has ensured that a thorough review of Ms R’s assessment has taken place by two alternative clinicians, whom are in agreement with her assessment outcome. For this reason, it is unable to offer a second assessment.
31. We have considered the GMC’s Good Medical Practice guidelines, which say clinicians should:
• making the care of patients the first concern • providing a good standard of practice and care, and working within competence • working in partnership with patients and supporting them to make informed decisions about their care • treating colleagues with respect and help to create an environment that is compassionate, supportive and fair • acting with honesty and integrity and being open if things go wrong • protecting and promoting the health of patients and the public
32. The Provider’s guidance says clinicians should complete ADHD assessments within one hour, but additional time or follow up appointments can be arranged if a case is more complex. There is no specific the Provider guidance about the provision of a second opinion.
33. However, all patients have the right to seek a second opinion if they have concerns about their diagnosis or treatment. Our adviser explained that usually, where there are factual errors within the assessment that may have affected the outcome, a second opinion should be offered. Additionally, where standard practice or guidelines have not been adhered to, a second opinion would be appropriate.
34. In reviewing Ms R’s assessments with our adviser, we can see Ms R had two one-hour appointments with the same clinician as part of her ADHD assessment. This was more than the minimum time set out in the Provider’s guidance due to the complexities of her case. As we have detailed earlier in this statement, we consider the assessment was carried out in line with standard practice and wider guidelines on what ADHD assessments should include.
35. We also saw that a second clinician, the supervising consultant psychiatrist, reviewed the assessment and agreed with the original clinician’s conclusion. Upon Ms R’s request for a second opinion, the Provider’s ADHD clinical lead also reviewed the assessment and outcome. We consider acted as an independent review of the assessment and decision reached. Both clinicians agreed there were no indications a formal second opinion was required.
36. On this basis, we are satisfied that the Provider followed its own guidelines, acted appropriately in line with the GMC’s Good Medical Practice guidance, and fairly considered Ms R’s request for a second assessment.
37. Related to this, we noted that in the assessment report, the clinician recognised that Ms R had a complex clinical history, including long-standing anxiety, emotional dysregulation, and that she had reported obsessive-compulsive symptoms and trauma. The clinician therefore recommended that Ms R’s GP consider referring her to a General Adult Psychiatry service for further assessment. The was to ensure that these difficulties could be explored more fully by an appropriate specialist service.
38. We consider this advice to be consistent with the GMC’s good medical practice guidance referenced above. Our adviser explained that, for patients with complex presentations, it is often appropriate to assess and address other potential diagnosis before confirming or excluding ADHD. By suggesting a further referral to another practitioner, this would allow for additional consideration of Ms R’s symptoms and presentation.
39. We are aware Ms R’s GP has since referred her for further assessment, including an Autism assessment. Based on the evidence available, we did not identify any indications of service failure in the actions of the Provider when considering if a second assessment was required.
Issue three – conduct of the clinician
40. Ms R says the clinicians conduct was inappropriate, specifically she says he was rude and said medication would not work on people her age. Ms R says she was very upset by this comment and left her assessment distressed.
41. In response to the complaint, the Provider says it escalated this to its Clinical ADHD Lead for review who has watched the assessment recordings. The Provider explained it was sorry to hear Ms R was not happy with her appointment, but concluded the assessor acted professionally. It did not identify any rudeness within the appointment.
42. The Provider acknowledged that Ms R noted within her complaint that her clinician told her when discussing medication that it ‘doesn't work for people your age’, which left her feeling shocked. It explained that, having reviewed her assessment recording, it can see that her clinician noted medication is needed to be managed differently depending on certain factors such as age. When Ms R sought clarification on this, her clinician confirmed this can be due to things such as cardiology, as ADHD medication can affect patient’s hearts.
43. The Provider said it is truly sorry for communication confusion and that Ms R had been left feeling her clinician was not supportive of medication due to age. It advised it would like to assure her that this was not its intention, and it provided this information to inform her with its best intentions in mind.
44. To consider this part of the complaint, we have reviewed the GMC’s Good Medical Practice guidance, outlined in paragraph 29 of this statement. We have also considered NICE G87, which gives clinicians guidance on prescribing medication for patients with ADHD.
45. NICE G87 says clinicians should carry out a full review of the patient’s physical and mental health prior to prescription. This should take into consideration the patient’s medical history and any current medication they are taking. This is to ensure any contraindications are carefully considered (section 1.7.5). A contraindication is a factor which makes a treatment harmful for a person. NICE G87 also says a referral for a cardiology opinion is required prior to starting medication for ADHD in patients where there is a history of palpitations and hypertension (section 1.7.5).
46. On review, we understand Ms R’s upset when the clinician had explained that medication would require careful management due to factors such as age. Our adviser confirmed this type of consideration would be relevant for Ms R, if she did want to consider stimulant medication, as she has a history of stroke, hypertension, type II diabetes, palpitations and thyroid disease. This is because the stimulant medication often prescribed for ADHD can have cardiovascular effects, which requires careful consideration in older adults.
47. For these reasons, we consider the Provider acted in line with the NICE G87 and the GMC’s Good Medical Practice when discussing the risks and benefits of medication with Ms R and to make her aware it may not be as effective due to her age and medical history.
48. With regards to Ms R’s concerns about the clinician being rude, we were sorry to learn this was the experience she had and we appreciate this is not what she would have expected. We would expect staff to display a caring and empathetic attitude for each patient, and if this did not happen, we recognise how distressing and concerning this would have been for Ms R. It is important to state we do not dispute Ms R’s recollection of events.
49. We accept that the staff attitudes may not have been as expected. We also recognise that in some instances each person involved in the same conversation can come away with a different perception of its contents and what happened. One person’s perception of what was said does not invalidate another person’s opposing perception of the same comment.
50. Whilst we consider it was appropriate for the clinician to discuss medication and its risks, we recognise Ms R remains unhappy with what was discussed and the way it was discussed.
51. We can see from the Provider’s response it has acknowledged Ms R’s concerns and has provided a clear explanation and an apology for the experience she had. We consider this is proportionate to what happened, and in line with the NHS Complaint Standards with regards to being thorough and fair, and providing accountable responses. We hope this is reassuring for Ms R.
52. Overall, we have not identified any indications of service failure, and we will not be taking any further action on this part of the complaint.