A medical practice in the London Borough of Lambeth

7. Miss I complains about three specific issues, in relation to the care and treatment she has received from the Practice, and one in relation to how her complaint was handled. These are: • Miss I says her amitriptyline prescription of 100mg was stopped completely on 21 July 2020 and it should have been gradually stopped at a steadier rate • The Practice inappropriately prescribed pregabalin in July 2020, despite it previously causing her adverse reactions, as noted in her GP records. She was told she could only be prescribed pregabalin and there was no alternative.

• The Practice prescribed her paracetamol in September 2020, which was not adequate to manage her symptoms of hip pain, fibromyalgia, and three bulging discs in her spine • Miss I says the Practice took too long to respond to her complaint.

8. Miss I says the abrupt reduction of her amitriptyline medication caused her to have flu like withdrawal symptoms. She says that as she was not prescribed an alternative medication, she has suffered with pain since July 2020. Miss I feels she was ignored when she was pursuing her complaint with the Practice.

9. Miss I wants an explanation and an apology from the Practice.

10. Miss I’s amitriptyline medication was stopped in July 2020. Miss I says she had a telephone consultation with her GP, and she was told she would either have to be prescribed pregabalin or go without the medication.

11. Miss I complained about this in August 2020, and she had a meeting with the Practice in September 2020.

12. Miss I emailed her outstanding concerns to the Practice after the meeting, and she received the Practice’s final response to her complaint in November 2020.

13. Miss I then approached us with her complaint, and we decided the complaint was premature as the Practice should address her outstanding concerns.

14. The Practice then corresponded with Miss I and advised she would need to book a GP appointment to discuss her concerns as they were of a clinical nature. Miss I did not want to do this and so she brought her complaint back to us.

Miss I’s amitriptyline prescription

18. Miss I says her amitriptyline prescription was stopped in July 2020.

Miss I says she was only offered pregabalin as an alternative to this. Miss I says she explained the side effects pregabalin caused her, but the GP prescribed it anyway.

19. Miss I says because of her amitriptyline prescription being stopped, and not reduced gradually, she suffered flu like withdrawal symptoms.

20. In its response, the Practice said Miss I was seen in the rheumatology department of Hospital B on 30 January 2020, where she complained that the amitriptyline was making her drowsy and giving her the feeling she was hungover. The Practice said Miss I’s rheumatology consultant asked the Practice to consider stopping the amitriptyline and replacing it with either gabapentin, pregabalin, or duloxetine, and wait for a pain clinic appointment. The Practice said it continued prescribing Miss I with amitriptyline for her neuropathic pain.

21. During a telephone appointment in July 2020, the Practice said Miss I had declined gabapentin, and anything that might make her drowsy, and she was prescribed pregabalin. The Practice said its system did not flag up that Miss I had an allergy to pregabalin, but it acknowledged its records did show that it caused her dizziness, and it apologised for this.

22. To consider if stopping Miss I’s amitriptyline suddenly was appropriate, we obtained clinical advice on this and we looked at the British National Formulary (BNF) guidance.

23. The BNF guidance on Amitriptyline Hydrocholoride says the risk of withdrawal symptoms are increased if the antidepressant is stopped suddenly after regular administration for eight weeks or more. The dose should preferably be reduced gradually over about four weeks, or longer if withdrawal symptoms emerge (six months in patients who have been on long-term maintenance treatment). If possible, tricyclic (a type of antidepressant drug) and related antidepressants should be withdrawn slowly.

24. Our clinical adviser said that Miss I had been prescribed amitriptyline for more than two years. Therefore, the Practice should have reduced the dose that Miss I was receiving gradually. This should have been done by reducing the 100mg per day dose that Miss I was receiving by 25 mg each week over a four week period. In line with the BNF guidance, this could have been done over a longer period if Miss I was experiencing withdrawal symptoms.

25. Our clinical adviser said the GP should have had a discussion with Miss I about how this was going to happen, but we have seen no evidence in Miss I’s GP records of a discussion about the stopping of amitriptyline.

26. The NHS outlines that withdrawal symptoms can include restlessness, trouble sleeping, unsteadiness, sweating, stomach problems, feeling irritable, anxious, or confused or feeling as if there’s an electric shock in your head. We do not consider it appropriate for the Practice to have completely stopped Miss I’s amitriptyline prescription, as the flu like symptoms Miss I suffered after the amitriptyline was stopped are similar to the withdrawal symptoms associated with stopping amitriptyline.

27. As such, we have identified a failing with the Practice’s decision to have stopped amitriptyline abruptly. We will make a recommendation to put right the impact this had on Miss I later in our report.

Miss I being prescribed pregabalin

28. Miss I says that she had a telephone consultation with her GP in July 2020 when her amitriptyline medication was stopped. She was prescribed pregabalin and told there was no alternative to this.

29. In the Practice’s response, it stated Miss I had declined gabapentin and anything that might make her drowsy, during a telephone consultation with her GP in July 2020, and she was prescribed pregabalin. The Practice said its system did not flag up that Miss I had an allergy to pregabalin, but it acknowledged its records did show that it caused her dizziness. It has apologised for this.

30. To determine if it was appropriate to prescribe Miss I pregabalin and not offer her an alternative medication, we have looked at the relevant guidance and received clinical advice.

31. ‘Domain 1. Knowledge, Skills and Performance’ of the GMC guidance on applying knowledge and experience to Practice says: ‘to 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 serve the patient’s needs. To provide effective treatments based on the best available evidence and to take all possible steps to alleviate pain and distress whether or not a cure may be possible’.

32. Miss I says she told the GP that she’d had side effects from pregabalin when she had taken this medication previously, but she was informed that this was the only alternative to amitriptyline that she could be prescribed.

33. The GP records show Miss I was prescribed 25mg of pregabalin twice a day, which our adviser has told us is a low dose. Miss I’s rheumatologist had written to the GP on 30 January 2020 and advised that the GP consider stopping amitriptyline, due to the side effects it was causing. They advised that duloxetine, gabapentin or pregabalin could be prescribed as an alternative.

34. The GP records show that Miss I declined gabapentin and anything that would make her drowsy at her telephone consultation with her GP on 28 July 2020. As such, our adviser said it would have been appropriate to have prescribed Miss I duloxetine.

35. There is no evidence that the GP discussed or considered this option with Miss I. Based on the clinical advice we have received, it would have been appropriate for the Practice to have discussed the option of prescribing duloxetine as an alternative, but this did not happen.

36. As such, we have identified a failing with the Practice’s decision to have prescribed Miss I pregabalin.

37. We can see the Practice has acknowledged it was in Miss I’s GP records that pregabalin caused her dizziness and it has apologised this was overlooked. However, the Practice has not specifically apologised to Miss I for prescribing pregabalin.

38. Miss I was caused worry and concern at being prescribed pregabalin and being informed there was no other alternative. We have explained this further in the impact section of the report and we have made a recommendation of action the Practice should take to put this right.

The Practice’s prescribing of paracetamol to Miss I

39. Miss I says the Practice prescribed her paracetamol in September 2020, which was not adequate to manage her symptoms of hip pain, fibromyalgia, and three bulging discs in her spine. She says because of this her pain was not managed.

40. The Practice has not provided a direct response to this point. It stated that during July and August 2020, Miss I had two consultations with the Practice, and she did not mention the adverse reaction she had suffered to pregabalin or ask for an alternative medication.

41. ‘Domain 1 on Knowledge, Skills and Performance’ of the GMC guidance on applying knowledge and experience to Practice says ‘to 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 serve the patient’s needs. To provide effective treatments based on the best available evidence and to take all possible steps to alleviate pain and distress whether or not a cure may be possible’.

42. The minutes of the meeting that Miss I had with the Practice on 15 September 2020 show that she was prescribed amitriptyline and paracetamol following the meeting she had with the Practice. This was in response to her having raised concerns about her amitriptyline being stopped and pregabalin being prescribed instead, and Miss I stating she had been in pain from July to September 2020.

43. Our adviser said while Miss I being prescribed paracetamol would not have caused her any harm, it would not have been the most appropriate pain relief to have prescribed to her. Based on her widespread pain, and having previously been prescribed stronger pain relief medication, such as co-codamol. We have found it would have been more appropriate for the Practice to have prescribed Miss I with duloxetine at that time, as the rheumatologist recommended.

44. As we have found that prescribing paracetamol would not have been effective in managing Miss I’s symptoms, we have identified this to be a failing. We have found this led to Miss I’s symptoms of pain not being managed as effectively as they could have been.

The time it took for the Practice to respond to Miss I’s complaint

45. Miss I says the Practice took too long to respond to her complaint after she had raised concerns with the Practice in August 2020.

46. Miss I requested a meeting with the Practice on 25 August 2020 and she sent a formal complaint on 1 September 2020. A local resolution meeting between Miss I and the Practice took place on 15 September 2020. Miss I was sent a follow up response and the minutes from the meeting on 7 October 2020.

47. Miss I sent a response back to the Practice on 15 October 2020 outlining her outstanding concerns. The Practice provided a response to Miss I on 4 November 2020 and Miss I sent a response back to the Practice on 5 November 2020. The Practice sent Miss I a holding email on 11 November 2020 to say it would be sending a further response and on 17 November 2020 the Practice invited Miss I to attend a second meeting. Miss I replied on the same day to say she did not want to attend a further meeting. The Practice then sent Miss I its final response on 17 November 2020.

48. Our principles of good complaint handling say public bodies should deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate.

49. From the evidence we have considered, we consider the Practice responded to Miss I’s complaint in line with our principles. The Practice had a local resolution meeting with Miss I within 30 days of her raising concerns. It then provided her with three further responses in October and November 2020.

50. We have found the Practice has acted in line with our principles of good complaint handling and we have not identified a failing with the length of time it took for the Practice to respond to Miss I’s complaint.

Our findings in relation to impact

Miss I’s amitriptyline prescription

51. We have identified a failing with the Practice’s decision to stop Miss I’s amitriptyline prescription abruptly. Based on the clinical advice we have received and the BNF guidance, we have found this led to Miss I suffering flu like symptoms in the weeks after her medication was stopped. Miss I was also caused worry and concern at her amitriptyline being stopped.

Miss I being prescribed pregabalin

52. We have identified a failing with the Practice’s decision to prescribe Miss I pregabalin. Miss I had previously suffered a bad reaction to pregabalin and the decision to prescribe her this would have caused her worry and concern, as she was aware she was likely to suffer a bad reaction to it.

The Practice’s prescribing of paracetamol to Miss I

53. We have identified a failing with the Practice’s decision to have prescribed Miss I with paracetamol. We have found the paracetamol was not sufficient to have managed Miss I’s symptoms of hip pain, fibromyalgia and the three bulging discs in her spine.

54. We consider the recommendations we have outlined below are sufficient to remedy the impact to Miss I that we have identified. We were very sorry to learn of the issues Miss I has brought to us, we appreciate she has been through a difficult time at what was already a concerning time for her.

1. We have identified three failings in our investigation, and we will be partly upholding Miss I’s complaint.

2. We have found it was inappropriate for the a medical practice in the London Borough of Lambeth (the Practice) to stop Miss I’s amitriptyline prescription abruptly in July 2020. We have found this led to Miss I experiencing flu like symptoms.

3. We have also found the Practice inappropriately prescribed pregabalin to Miss I in July 2020. This caused Miss I worry and concern, as she had previously had a bad reaction to pregabalin.

4. Thirdly, we have found it was not appropriate for the Practice to have prescribed Miss I paracetamol in September 2020 as this would not have been adequate to manage her symptoms.

5. We will be asking the Practice to write to Miss I to apologise for the impact its actions have caused, and to provide an action plan to help ensure the failings we have identified do not happen again.

6. We were very sorry to learn of the issues that Miss I has raised with us. We understand she has been through a difficult and concerning time.