Management of medication
22. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation 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 something has gone wrong.
23. Mr R complains the Practice did not adequately review his sister’s medication and the side effects she reported. He has told us how his sister suffered with mental health issues and suicidal ideation which resulted in two attempts to end her life. We were deeply saddened to hear that Miss O completed suicide in November 2023.
24. We recognise the devastating impact the loss of Miss O has had on Mr R and his family. We understand this was made more distressing when he accessed his sister’s medical records as part of claiming on her estate and unexpectedly saw instances that his sister accessed care at the Practice for difficulties with her mental health and suicidal ideation. We have listened when Mr R has told us that this discovery felt like missed opportunities to provide his sister with appropriate support and care.
25. In its response the Practice apologised that Mr R felt the prescription of an antidepressant caused Miss O to feel suicidal. The Practice explained Miss O sought support on 22 June 2022 for difficulties sleeping due to work-related pressure. It noted Miss O had used over the counter sleeping aids and sought help from a sleep charity to improve her sleep health. The Practice said it agreed an interim trial of promethazine for sleep management with Miss O.
26. The Practice said in July 2022 it prescribed a low dose of mirtazapine (an antidepressant) as part of its ongoing treatment and management of her sleep problems and depression. It said it risk assessed Miss O at each appointment for mixed anxiety, low mood and sleep. It notes Miss O told the Practice she found the treatment beneficial.
27. In its response the ICB issued its condolences for Mr R and his family. It said on review of the medical records it considered the Practice’s consultations and treatment as appropriate. It noted Miss O stopped the mirtazapine herself after two weeks and was switched by the Practice to paroxetine (an antidepressant) which had been previously tolerated well.
28. Miss O first attended the Practice on 22 June 2022 reporting symptoms of low mood. This is the first instance of a discussion of this nature for quite some time in Miss O’s records. During this appointment the Practice discussed professional and personal influences on Miss O’s mood and stress. It also noted what social support Miss O had in place. The records indicate Miss O did not report any suicidal ideation at this appointment.
29. The Practice discussed medication and whilst Miss O declined anti-depressants she did accept the prescription of promethazine. Our adviser explained whilst promethazine is commonly an antihistamine it can often be prescribed for short term insomnia. This consultation ended with review as needed.
30. Our adviser noted this consultation considered Miss O holistically and assessed the risk to self and considered the support available to her. Our adviser explained this was a good consultation in line with professional GMC standards which state when providing professional clinical care a doctor should:
• adequately assess a patient’s condition, taking account of their history, including symptoms and relevant psychological, social and economic factors • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary • propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs
31. On 5 July, the Practice had a telephone consultation with Miss O. This consultation reviewed reported effectiveness of promethazine for Miss O’s insomnia, and the Practice prescribed an increased dosage. The records indicate the Practice discussed starting mirtazapine with Miss O if promethazine was not helpful. The Practice agreed to review and follow up with Miss O within two to four weeks.
32. After this appointment Miss O attended the emergency department of a local hospital where she was seen for management of her sleep hygiene on 8 July. Miss O was discharged from the hospital as low to no risk of self-harm. The Practice arranged a same day face to face appointment with Miss O.
33. During this consultation the Practice discussed Miss O’s current triggers and medications. It noted Miss O reported ‘feeling suicidal’. We have seen this was explored with Miss O and the Practice was reassured Miss O did not have any plans to harm herself. The records from this consultation detail the triggers to Miss O’s mental health were related to being off work and her insomnia which she described as exacerbating her anxiety and depression.
34. The Practice discussed Miss O’s previous use of paroxetine (an anti-depressant). We are unable to comment on Miss O’s previous prescription of this medication as this is outside of the scope of our consideration. We have seen in this consultation the Practice noted Miss O had previously tolerated paroxetine well though it was not prescribed at this appointment because Miss O wanted to address and manage her difficulties with insomnia.
35. The Practice prescribed a small dose of zopiclone which is a medication used for the short-term management of insomnia. The Practice agreed to review Miss O within three days.
36. The Practice reviewed Miss O by telephone three days later as agreed on 11 July. It noted Miss O had started to use mirtazapine which she was responded well too. Our adviser explained this consultation looked at the social support Miss O had available to her. It noted she had a friend she relied on for support and had cognitive behavioural therapy (CBT) planned for the following week. The Practice agreed to review Miss O again in seven days.
37. Our adviser explained this consultation was appropriate for Miss O. It considered all aspects relevant to her safety and treatment in line with NG222. NG222 notes the recommendations for treatment of a depressive mood disorder is medication and CBT.
38. The Practice reviewed Miss O a week later, on 18 July to discuss how she was getting on with mirtazapine and zopiclone. At this appointment Miss O disclosed she felt ‘zoned out’ and was experiencing suicidal thoughts. Miss O reported this was linked to thoughts of her not being able to do her job and the risk of her losing her flat.
39. The Practice advised Miss O to attend the emergency department if acutely suicidal. The Practice also arranged an afternoon appointment due to the concern over her disclosure. The Practice consulted her in the afternoon, and the consultation considered Miss O’s presentation, discussed her suicidal ideation and the triggers behind this which were linked to finances, mortgage and work.
40. The Practice noted Miss O had made an attempt to harm herself over the weekend which she stopped quickly. The Practice discussed a safety plan, crisis line numbers and reiterated she attend ED (emergency department at the hospital) if acutely suicidal. Our adviser explained this was a robust consultation which assessed Miss O completely and was actioned efficiently.
41. On 25 July, the Practice had a telephone consultation with Miss O. This appointment was arranged as a follow up to an email that Miss O sent to the Practice disclosing ideas of self-harm. Our adviser noted this consultation, like the previous, was complete and considered all aspects of Miss O’s mental health issues and triggers. It also considered support available and what plans she had in place to access support. The Practice noted Miss O declined a referral to a community mental health team (CMHT) and was keen to explore private clinics.
42. During this appointment the Practice discussed paroxetine with Miss O, and it noted she had tolerated this well and was happy to try this. It noted she had stopped taking the mirtazapine, had no suicidal thoughts and had social support in place with plans to meet a friend.
43. Our adviser noted the discussion on prescribing paroxetine was not as detailed as expected, in comparison to previous records, though our adviser explained it is possible this is not noted as Miss O had taken this previously. We do not consider this to be a failing, rather a short coming. We consider this was a single incidence where the Practice’s record keeping fell short of the expected standard but not so far short to be considered a failing. Our adviser noted the impact of this was minimal as the Practice provide clear information on monitoring symptoms and who to contact if in acute need.
44. We recognise Mr R had concerns the Practice did not adequately review his sister’s medication and the side effects she was reporting.
45. Our adviser explained suicidal behaviours is an uncommon side effect in the use of anti-depressants such as paroxetine and whilst it is a side effect it is not possible for us to link this to the paroxetine. This is because this behaviour was experienced prior to starting the medication. Our adviser also explained Miss O was advised to contact the acute crisis team, 111 or the emergency department in numerous consultations for acute management of suicidal ideation which is the recommended action in NG222.
46. A day later, on 26 July, Miss O was seen face to face at the Practice. She reported ongoing suicidal thoughts though ‘not acutely’. We would like to explain this is a clinical term which means the disclosure of suicidal ideation that Miss O disclosed was not considered to be with a plan, immediate or life threatening. The Practice noted Miss O had plans to see a friend, attend counselling and then update the surgery.
47. Two days later Miss O was detained at a place of safety by a local CMHT following behaviour in public that was high risk of harm to self. The Practice contacted Miss O by telephone once notified to discuss her feelings and the support she would be receiving by the CMHT. Our adviser noted this was very good practice as secondary care was involved at this point.
48. From this point Miss O’s care was transferred to the CMHT and home treatment team and the Practice had one telephone call with her on 15 August to review medications and ongoing mental health support. Our adviser explained this consultation appeared positive with the ongoing support she was receiving from secondary care.
49. Sadly, Miss O made an attempt to end her life in September 2022 which was unsuccessful. She provided consent for the Practice to contact her friend whilst she was in hospital. Our adviser explained this telephone call noted Miss O’s friend’s concern and discussed who the friend could contact going forward as Miss O’s care was being taken over by a local Trust’s psychiatric team. Our adviser also noted there is no interaction after this regarding Miss O’s mental health as the care was taken on by secondary care and local MHT.
50. We understand that reading about these medications caused Mr R distress and upset. We recognise it was not easy to learn of the difficulties his sister was experiencing. We do not underestimate that Mr R felt significant frustration and concern that his sister’s death could have been prevented.
51. We have used the medical records to look at the care and treatment the Practice provided. We have considered whether this is in line with the relevant professional and medical guidance. We are satisfied that the Practice acted in line with GMC professional standards in its provision of care and treatment to Miss O. We understand this decision may be difficult for Mr R. We hope our explanations provides reassurance that the Practice acted appropriately in the care and treatment it provided his sister.
52. We are reassured the Practice responded promptly with each disclosure and arranged face to face consultations when necessary to ensure Miss O’s safety and wellbeing. We are satisfied with how the Practice conducted its consultations and follow ups in its management of Miss O’s MH.
53. We have seen no indication of failing in this part of Mr R’s complaint and will not consider this complaint further. We are sorry for any additional distress and upset our decision may cause.
Complaint handling
54. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation 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 something has gone wrong.
55. Mr R complains the Practice poorly handled his complaint and did not provide full unredacted documents. We have listened when Mr R has told us this felt as though the Practice was intentionally omitting information.
56. The Practice’s complaint handling policy explains there are strict rules of confidentiality when there are complaints made on behalf of someone else. There are exceptions to this for example, patients of ill health or who are deceased.
57. The Practice’s complaint policy says a personal representative needs to authorise the release of information when a complaint is made on behalf of a deceased patient. It also says in these circumstances that the information released is related to the relevant claim whilst maintaining confidentiality on additional information that may have been sensitive to the patient.
58. We contacted the Practice to better understand what happened when it issued redacted documents to Mr R. The Practice says this was explained to Mr R in an email on 19 December 2024. In this email the Practice explained ‘a deceased person still has rights of confidentiality and when we receive a record request for a deceased persons information, we have to review this in line with the Access to Health Records Act 1990’.
59. The Practice explained it could only allow access to the Miss O’s health records for either: • ‘a personal representative (the executor or administrator of the deceased person's estate) • someone who has a claim resulting from the death (this could be a relative or another person), in which case we can only release information directly relevant to the claim.’
60. The Practice noted Mr R said he fell into the second category as a claimant of his sister’s estate.
61. We recognise the rules and regulations around personal data and disclosure are strict. We consider the Practice acted with caution when it considered Mr R’s request to access his sister’s medical records and did so in line with its complaint policy.
62. We understand why the Practice’s scrutiny of his records request added to an already stressful and deeply upsetting situation. We have seen no indication of failing in the Practice acting in line with its policy.
63. We thanks Mr R for bringing his complaint to us and for sharing information about such personal and distressing events. We hope our explanations, in time, offer him some reassurance.