An practice in the Northumberland area

6. Mr W complains the Practice:

• made mistakes with how it managed his diazepam prescription between February 2020 and January 2021 • incorrectly prescribed him prednisolone in December 2020.

7. Mr W says the Practice’s mistakes caused him stress and anxiety because he had to manage his own diazepam prescription. He says his anxiety and depression became more serious and caused him problems with his liver. His memory became worse and he describes himself as ‘zombie-like’, so he had to have psychotherapy.

8. He says he was unable to work so he lost his income. He could not do volunteer activities and lost interest in his hobbies.

9. Mr W wants the Practice to acknowledge its failings and to make a financial payment to him.

10. Mr W was diagnosed with autism spectrum disorder (ASD) and anxiety. He was getting treatment from the Practice and his local community mental health team (CMHT).

11. In about October 2019, Mr W attended his local emergency department due to a mental health crisis. He was treated with diazepam and the hospital asked the Practice to continue prescribing it. He was also taking mirtazapine, an antidepressant.

12. On 10 February 2020, the Practice prescribed Mr W with 8mg of diazepam each day. He had an appointment with the CMHT the next day. The consultant psychiatrist wrote to the Practice to ask it to start reducing Mr W’s prescription by 1mg every two weeks.

13. By 5 April, the Practice had reduced Mr W’s diazepam prescription to 5mg each day.

14. On 6 April, Mr W saw a GP at the Practice. He explained he was struggling to sleep and was feeling more anxious and he felt it was because of the reduced diazepam. The Practice increased his diazepam prescription to 6mg each day and increased it again a week later to 12mg daily.

15. On 30 November, the Practice reduced Mr W’s diazepam prescription to an average of 9mg every day. It continued to reduce the prescription until it stopped the treatment in April 2021.

The Practice’s diazepam management

20. Mr W complains the Practice did not prescribe the correct amounts of diazepam and made mistakes when it was reducing his doses with a view to stopping the treatment.

21. We have taken clinical advice to help us with this part of Mr W’s complaint. Our adviser told us which guidance the Practice should follow when managing Mr W’s diazepam reduction and whether it acted in line with it. This is the NICE guidance on benzodiazepine because diazepam belongs to this group of medicine.

22. This guidance is extensive, so we focused on the parts most relevant to Mr W’s complaint. It specifically guides clinicians on how to withdraw diazepam for patients with anxiety. It says the clinician should explain anxiety is the most common withdrawal symptom, reassure them it is likely to be temporary and to consider slowing or suspending the withdrawal until the symptoms become manageable.

23. The guidance also says clinicians should monitor patients after a dose reduction and allow a dose increase if the withdrawal symptoms are very difficult to manage. The increase must only be to the dose before the latest reduction and after the symptoms have been monitored for one to four weeks.

24. Mr W had an appointment with the CMHT on 11 February 2020. At the time, he was taking 8mg of diazepam daily. After the appointment, the CMHT wrote to the Practice explaining it should start to reduce his diazepam prescription by 1mg every two weeks.

25. We can see from Mr W’s records that the Practice started to slowly reduce his diazepam prescription. From the date of the CMHT appointment to 5 April it reduced his prescription to 5mg daily.

26. On 6 April, Mr W had a consultation at the Practice. He complained he was feeling much more anxious since reducing his daily diazepam dose. The consultation record says the doctor changed the prescription to ‘2 tds’. This means for Mr W to take two tablets, three times a day, which is 12mg of diazepam. But, the actual prescription was for one tablet, three times day, which is 6mg of diazepam.

27. The prescription of 6mg was in line with the NICE guidelines as it was the last dose Mr W found tolerable. He had also been taking the reduced dose for three weeks, which is within the timescale the guidance allows. But, we cannot see the GP reassured him about the symptoms and how common they can be. It made a mistake here.

28. One week later, on 13 April, the Practice prescribed Mr W 12mg of diazepam. This is consistent with the Practice’s consultation records when it recorded ‘2 tds’. He continued to be prescribed 12mg of diazepam until 18 May, when the Practice again reduced the prescription to 6mg.

29. Between then and 3 July we can see the Practice allowed Mr W to order twice the amount of the prescribed diazepam. It prescribed two weeks’ worth of medication, but Mr W was submitting a repeat prescription request every week and the Practice was issuing this each time. So, it allowed him to continue to take 12mg daily.

30. On 3 July, the Practice changed the prescription back to 12mg of diazepam daily. It continued like this until 30 November, when the Practice started to reduce his daily dosage again.

31. There were two issues for us to look at here. Whether the Practice was right to increase Mr W’s diazepam to 12mg daily and how it should have managed the diazepam reduction.

32. The increase was not in line with NICE guidance. We cannot see Mr W complained again of withdrawal symptoms to support considering another increase. Also, if he was feeling withdrawal symptoms taking 6mg daily, the next tolerable dose would have been the last prescription of 8mg. We have not seen evidence to support an increase to 12mg.

33. The NICE guidance gives a clear indication of how the Practice should have reduced Mr W’s diazepam. It says the withdrawal should be based on reducing the prescription by 0.5-1mg every two weeks if the daily dose is 5mg or less. It also says if an increase was necessary, there should be a period of stabilisation before restarting a more gradual reduction.

34. The records show Mr W’s diazepam dose was 5mg daily from 16 March. The Practice should have been using the NICE guidance from this point and reducing his dose by the amount shown above. We realise it had to slightly increase the daily dose on 6 April due to Mr W’s symptoms. Unfortunately, within a week of this increase, it had increased Mr W’s prescription by double, to 12mg. It should have followed the NICE guidance by allowing Mr W to stabilise on 6mg daily, before starting to reduce his dose more gradually.

35. The Practice made mistakes in how it managed Mr W’s diazepam prescription from 13 April, when it increased his daily dose to 12mg, until 30 November when it started the CMHT’s reduction plan.

36. We understand Mr W’s reasons for bringing this complaint to us and the impact long-term benzodiazepine use can have on someone, which is what we will consider next.

The impact the Practice’s mistakes had on Mr W

37. Mr W complains the Practice’s mistakes made his stress and anxiety worse, made him ‘zombie-like’ and caused him physical problems with his liver. He also said he could not live his life how he used to, he could not enjoy his hobbies and could not work.

38. We have considered the likely impact of the Practice’s mistakes. Our adviser highlighted information from the mental health charity Mind’s website to help us make this decision. Mind gives an overview of the symptoms and impact anxiety can have on someone. The symptoms it lists include low mood and dissociation (where you feel disconnected from your mind or body, or from the world around you). It also says it can cause difficulties with everyday parts of someone’s life, like work or enjoying leisure time.

39. Mr W has told us he has experienced these symptoms. We need to consider whether there is evidence to suggest his diazepam use between 13 April and 30 November caused them.

40. The CMHT wrote to the Practice several times while Mr W was reducing his diazepam dose. It is clear from its letters he felt anxious and it was something he had been experiencing for a long time. We appreciate how difficult it can be to live with anxiety and the impact it can have on someone’s daily life. We are sorry to hear how it was making Mr W feel.

41. The letters from CMHT are a key piece of evidence for us when we are looking at the impact of the Practice’s mistakes. They show anxiety was present in Mr W’s life for a long time, both before and while he was taking diazepam. He has told us this feeling is much worse since stopping diazepam and he feels it is because of the length of time he was taking it.

42. Our adviser also highlighted how there is overlap of the symptoms of anxiety and the side effects of diazepam. As we have seen, anxiety is also a symptom of withdrawal from long-term diazepam. Mr W could have experienced anxiety simply because he was taking the medication or because he was withdrawing from it, despite the Practice’s errors.

43. Overall, we cannot say the Practice’s mistakes with how it managed Mr W’s diazepam was the cause of his anxiety and the symptoms anxiety can cause. We cannot say his anxiety would have stopped if the Practice had managed his diazepam better.

44. Mr W told us his anxiety has got worse since he stopped taking it. Professor Ashton’s guidance gives us some more information to help us with this decision. It says anxiety after stopping diazepam use can happen while a person learns new techniques to manage stress and anxiety. It says the anxiety may have always been there but was being masked by the diazepam. This is relevant to the complaint as Mr W had anxiety before he started using diazepam.

45. We appreciate the uncertainty the Practice’s mistakes caused for Mr W. He will never know how he would have felt if the Practice had managed his diazepam reduction in line with the guidance and how this may have affected his anxiety. This was made worse because the Practice did not explain that he could experience anxiety as a side effect of withdrawing from the medication. His uncertainty is not limited to the period when the Practice was managing his diazepam medication, it will always be there. It is important the Practice accepts this which we have explained in our recommendations at the end of this report.

46. Mr W also told us the amount of diazepam he was being prescribed has caused damage to his liver. He told us he did have liver disease and we know he was alcohol dependent before the time period he complains about. The British National Formulary gives information about prescribing medicines. The information it gives for diazepam says care should be taken prescribing it for people with a history of alcohol dependence. It says when prescribing for anxiety and to people with a history of alcohol dependence, it should limit the daily dose to 15mg in divided doses.

47. We have already given our view on how the Practice was managing Mr W’s diazepam prescription and we found it made a mistake. But, we cannot say it has caused the liver problems Mr W describes. This is because the Practice was prescribing diazepam within the limits outlined in the British National Formulary for people with anxiety and a history of alcohol dependence.

The prednisolone prescription

48. Mr W complains the Practice wrongly prescribed him prednisolone instead of diazepam on 16 December 2020. He said this added to the anxiety he was feeling from reducing his regular diazepam dose.

49. We can see in Mr W’s records the Practice wrongly prescribed him 113 tablets of prednisolone. He immediately told the Practice and it replaced the prescription with the correct amount of diazepam tablets. It then destroyed the prednisolone.

50. We looked at what the Practice has done to resolve this part of Mr W’s complaint. It acknowledged it made a mistake with the prescription and apologised. It also told Mr W the clinician who made the mistake would discuss the incident during their annual appraisal.

51. Our NHS Complaint Standards explain what we think an organisation should do when it identifies where it has made a mistake which has had an impact on someone. In this case, the Practice should find a suitable and appropriate way to put things right for Mr W. The Practice has done this by giving a meaningful and sincere apology and openly reflecting on the impact the mistake had on him. There is nothing more we need to ask it to do to put things right.

1. We have found a GP practice in the Northumberland area (the Practice) made mistakes in how it managed Mr W’s diazepam prescription (used to treat anxiety) between April and November 2020.

2. We partly uphold this complaint. We are not fully upholding the complaint because we cannot say the impact of this mistake was as serious as Mr W describes, but we recognise it has left him with uncertainty about whether he could have had a better experience.

3. We are making recommendations for the Practice to acknowledge what it got wrong, apologise for the impact and to make a financial payment to him. We have also asked it to explain what it will do, or has already done, to learn from this complaint.

4. We are very sorry to hear how Mr W has not been able to do the things he used to enjoy doing and we hope his wellbeing improves in the future.

5. We have also looked at Mr W’s complaint about the Practice prescribing prednisolone (can be used to treat allergies, inflammation and infections). We are pleased to see the Practice acknowledged its mistake and apologised to him. The Practice has done enough to put things right for Mr W for this part of his complaint.