A practice in the Sheffield area

5. Mrs U complains about the poor care and treatment at the Practice since April 2024 for her mental health. She specifically complains the Practice has not provided any supportive interventions to meet her needs and delayed a prescription request for antihistamines to help her sleep.

6. Mrs U tells us the impact of this was her mental health deteriorated so much she suffered her worst breakdown to date. She says she had to remove herself from the family home to recover in a hotel. Mrs U is self-employed and so lost earnings whilst she was off sick recovering.

7. By bringing her complaint to us, Mrs U is looking for the Practice to acknowledge its poor care and treatment. She is also looking for the Practice to acknowledge the impact the delay in prescribing the antihistamine had on her mental health. She is also looking for a financial remedy.

8. Mrs U has suffered with her mental health for the past twenty years. In April 2024, Mrs U attended a GP appointment where she told the doctor she was struggling with anxiety and was experiencing panic attacks. She says she told the doctor her sleep was difficult. She says she was referred to the Primary Care Mental Health Team (PCMHT) during this consultation.

9. In July 2024, the PCMHT contacted Mrs U to complete a mental health screening. Mrs U did not feel she could engage with the PCMHT at that time and asked to rearrange.

10. In August 2024, Mrs U says she was experiencing physical symptoms such as twitching eyes and jaw clenching. She says she felt these were physical symptoms of stress. Mrs U felt her mental health was declining again in September 2024 and contacted PCMHT for support.

11. Mrs U contacted the Practice early in October 2024 about her mental health. She states she had doubled her antidepressants and had spoken with the PCMHT. She says her first appointment with the PCMHT was the first time she felt heard by someone about her mental health. Mrs U continued to seek support from the PCMHT. The PCMHT wrote to the Practice recommending it prescribes promethazine (a type of antihistamine) to help Mrs U sleep on 30 September. It raised its concerns about Mrs U being burnt out.

12. The Practice received the letter on 4 October 2024 and a GP actioned it the same day, asking the in-house pharmacist to issue two weeks of promethazine. Five days later the pharmacist returned the letter to the Practice’s admin team because they did not feel the medication was suitable. The doctor reviewed the letter and repeated their instruction from 4 October 2024.

13. On 15 October 2024, the pharmacist alerted the doctor that the mental health practitioner from PCMHT was not medically trained and was therefore unsuitable to make medical suggestions. The GP has apologised the message from the pharmacist was left in their task box and unfortunately overlooked.

14. In February 2025 when the Practice realised the message was still there, they contacted Mrs U, inviting her in to discuss whether the medication was still required. In the meantime, Mrs U says she felt at crisis with her mental health and on 27 November 2024 she tried to get onto the roof of her house with the intention of jumping off.

15. Through her work with PCMHT, Mrs U feels her mental health issues are signs of autistic burnout. The Practice has now referred her for an autism assessment. Mrs U feels the Practice has never taken a holistic approach to her mental health and feels the Practice has not suggested supportive interventions for her needs.

The Practice has not provided any supportive interventions to meet Mrs U's needs

19. Mrs U tells us she has suffered with her mental health for the past twenty years. She tells us she feels the Practice have not provided her with the right interventions for her needs since April 2024. Mrs U has recently been assessed for autism following discussions with the PCMHT. She questions why it is only now that autism is being considered.

20. Mrs U says in October 2024, following her first appointment with the PCMHT, she felt her mental health was declining. She says the Practice’s suggestion was to increase her sertraline (antidepressant) dosage. In December 2024 she says she experienced a mental health crisis where she attempted to get on to the roof of her home. She says she had to check herself into a hotel to recover. She says this was a build-up of her mental health declining and a lack of support from the Practice.

21. We are sorry to hear Mrs U did not feel the Practice supported her and how she considers this led to a deterioration in her mental health.

22. The Practice said when Mrs U discussed her situation with one of the GPs, the GP referred her to the PCMHT. The Practice acknowledged that accessing mental health services can be frustrating and apologised Mrs U’s experience did not meet her expectations. It also explained autism is a complex condition so diagnosis is challenging particularly when the individual is high functioning and the symptoms are associated with other conditions.

23. Mrs U’s records show she attended a consultation in April 2024 and explained she was struggling with anxiety and having panic attacks. During this consultation the GP agreed to refer her to the PCMHT. The records show the referral was made. The records also show the GP discussed an increase in Mrs U’s antidepressants and prescribed diazepam (medication for anxiety) after Mrs U asked for it. Mrs U also had consultations with a GP in August, September, October and December about her mental health.

24. We asked our adviser if the Practice took the appropriate interventions during each of these consultations. Our adviser said the Practice appropriately referred her to the PCMHT in April 2024. They said this was a service that would get to know Mrs U well through longer sessions than short consultations that a GP can give.

25. Our adviser said the discussions around increasing Mrs U’s antidepressants were in line with GMC guidance as it has promptly provided suitable advice and treatment for Mrs U’s needs.

26. GMC guidance states doctors should provide a good standard of practice and care by adequately assessing a patient’s condition and taking into account their history. It also states it should refer a patient to another practitioner when this serves the patient’s needs.

27. We consider the Practice appropriately referred Mrs U to the PCMHT based on the current state of her mental health and her history of mental health concerns. We can see from the records the PCMHT were able to build a rapport with Mrs U and provide her with the time and resources she needed to help address her mental health challenges.

28. NICE guidance states staff should consider assessment for possible autism when a person has one or more of the following: • persistent difficulties in social interaction • persistent difficulties in social communication • stereotypic (rigid and repetitive) behaviours, resistance to change or restricted interests • problems in obtaining or sustaining employment or education • difficulties in initiating or sustaining social relationships • previous or current contact with mental health or learning disability services • a history of a neurodevelopmental condition (including learning disabilities and attention deficit hyperactivity disorder) or mental disorder.

29. The PCMHT were able to talk to Mrs U in more detail about her mental health concerns and were able to recognise potential autism in Mrs U. Once the Practice were made aware Mrs U may need assessing for autism, it acted in line with NICE guidance by considering and making a referral for an assessment.

30. Based on the guidance above, we can see the Practice has acted in line with the above guidance when providing interventions and treatment to support Mrs U with her mental health. We have seen no indications the Practice did anything wrong.

The Practice delayed a prescription request of antihistamine to help Mrs U sleep.

31. Mrs U says the PCMHT wrote to the Practice in October 2024 to request it prescribe Mrs U promethazine (an antihistamine) to help her sleep. The Practice did not get in touch with her until February 2025. During this time, Mrs U says she experienced her worst breakdown to date. She tried to get on the roof of her house with a view to jumping off.

32. We are sorry to hear Mrs U’s mental health deteriorated drastically during this time and that she had to remove herself from the family home for a short period of time to recover.

33. The Practice admitted its delay and apologised with an explanation of how it happened. The GP actioned the prescription and sent it through to the pharmacist. It explains the pharmacist was acting in a safety netting capacity asking the GP to review the letter from the PCMHT as they were not sure the medication was suitable. The GP explained on 15 October 2024 the message from the pharmacist was left in their task box and was unfortunately overlooked. They explained they intended to discuss it with the PCMHT face-to-face however a suitable opportunity did not happen. The GP reflected on the situation and apologised sincerely.

34. In February 2025 when it came to the Practice’s attention they had overlooked the task, they invited Mrs U into the Practice to discuss the provision of sleeping medication to see if it was still required.

35. Our NHS complaints standards say when something goes wrong, staff should explain why things went wrong and identify suitable ways to put things right for people. It also states staff should give meaningful and sincere apologies.

36. We consider the Practice have acted in line with the above guidelines. The GP has apologised and explained what happened. They also attempted to put things right by inviting Mrs U into the Practice to discuss whether the medication was still needed.

37. In order to decide whether financial compensation is appropriate, we would need to explore the impact the claimed failing has had on Mrs U.

38. We appreciate Mrs U wanted the promethazine to help her sleep. She tells us she experienced her worst breakdown during this time and feels not having the prescription contributed to her reaching this crisis point.

39. On 6 February, the PCMHT records state Mrs U had been taking promethazine unprescribed as she was given it by her friend who is a GP. These records also state Mrs U told staff she was not concerned about the access to the promethazine but it was more the principle.

40. Having reviewed the evidence, we cannot see that there is a direct link between the Practice's late prescription of promethazine and the difficulties Mrs U unfortunately experienced in November when she reached crisis point. This is because she had access to it from another source during this period.

41. We appreciate the delay in medication was frustrating for Mrs U and would have caused her some inconvenience and distress. As part of our work, we have looked at this impact in line with our severity of injustice scale.

42. Our severity of injustice scale helps us determine whether a financial remedy is appropriate in cases. Level one explains that for low impact injustices such as annoyance, frustration, worry or inconvenience arising from a one-off incident with no lasting effects we generally consider an apology to be sufficient. In these cases, we would not usually consider a financial remedy to be appropriate.

43. We consider Mrs U’s impact of frustration and distress to stem from a one-off incident when the Practice delayed its prescription of the antihistamines. This aligns with those described in level one in our severity of injustice scale. In these circumstances, our severity of injustice scale says an apology is enough to put right impacts like this.

44. As the Practice has already apologised for what happened, we do not consider this complaint requires further investigation and will not be taking any further action.

45. We would like to thank Mrs U for taking the time and effort in bringing her complaint to us and we wish her well with her autism assessment .

1. We have carefully considered Mrs U’s complaint about the Practice. We are sorry to hear her concerns about how the Practice managed the care and treatment of her mental health since April 2024. From what she has told us, she has struggled with her mental health for a very long time and this has been a very distressing and difficult time in her life.

2. Based on the evidence we have considered, we have seen no indications that anything went wrong in the Practice’s care and treatment of Mrs U’s mental health. We have seen the Practice has followed relevant guidelines when it managed her concerns during consultations with its doctors.

3. In regards to the delay in prescribing the antihistamine to help her sleep, we have decided we cannot link this to Mrs U reaching crisis point in November 2024. We have explained our reasons for this in more detail in this statement.

4. We recognise how important this complaint is to Mrs U, and we would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint and gives her some reassurances that the Practice followed relevant guidelines.