A practice in the City of Westminster area

5. Ms G complains a pharmacist at the Practice delayed her lithium prescription on one occasion for at least two weeks between July and September 2024. Ms G says this was concerning for her, as abruptly stopping lithium can increase the risk of a manic or depressive relapse. She says it caused her distress and uncertainty. She also says she lost trust in the Practice and felt unsafe, so chose to leave. Ms G wants service improvements and a financial remedy.

6. Ms G has been taking lithium medication since 2015. In July 2024 the Practice sent her a text message advising her to arrange a blood test to monitor her medications.

7. Ms G attended the Practice a few days later and it carried out a blood test. Later, on the same day it documented her lithium levels as normal. At the end of July, Ms G requested a repeat prescription of her regular medications including lithium. The Practice issued the prescription on the same day but did not include the lithium prescription.

8. The Practice provided her with a prescription for lithium five days later. The Practice provided a further prescription for all medications including lithium at the end of August and Ms G moved to a different Practice at the beginning of September.

11. Ms G says a pharmacist at the Practice delayed her lithium prescription on one occasion for at least two weeks between the months of July and September 2024. She told us she was extremely concerned she would have a manic or depressive relapse which led to her experiencing increased anxiety and uncertainty. From what she told us this was a very distressing time for her, which we were sorry to hear about.

12. NHS England says lithium treatment should not be stopped suddenly, as this can cause relapse. It says it is recommended that lithium levels should be monitored at least every 12 weeks for the first year and then every six months.

13. Ms G’s records show the Practice sent her a text message in the middle of July to attend for a blood test to monitor her medications. It carried out a blood test on Ms G the following week. Later the same day it documented her lithium level as normal. A few days later she requested a prescription for several medications. It is unclear from Ms G’s records whether she included lithium in her request. However, the Practice has confirmed she added this in, in writing at the bottom of her request.

14. The Practice provided her with a prescription on the same day for all medications other than lithium. It provided her with a prescription for lithium five days later. Ms G requested a further prescription for lithium at the end of August, and the Practice provided it on the same day.

15. It appears the Practice delayed providing Ms G with a lithium prescription for five days at the end of July. We have seen no evidence of any other delays between July and September.

16. Our clinical adviser says the pharmacist at the Practice should have balanced Ms G’s need for a stable supply of lithium with making sure the Ms G’s blood levels were within a normal range. We could not see any evidence the Practice documented any concerns about lithium toxicity and there is evidence she had a blood test in May which showed her lithium levels were within normal range. Our clinical adviser therefore explains the Practice should have continued with her lithium prescription in July without delay.

17. The delay of five days is not in line NHS England guidelines which says lithium treatment should not be suddenly stopped. We cannot see the Practice documented any reason for the delay in Ms G’s records and it recorded her lithium levels as normal.

18. Ms G says suddenly stopping lithium increases the risk of manic or depressive relapse which she told us led her to feel uncertainty and fear that this may happen to her. She says the delay interrupted her professional responsibilities as she had to make numerous trips to the Practice to confirm if her lithium had been prescribed. She also says she lost trust in the Practice which led to her moving to another Practice.

19. In its final the response the Practice explained there was an issue with it getting her medications coordinated earlier. It said lithium requires blood level monitoring and the level needed checking before it could issue the medication. It went on to say this can take some time to add to the system and check. It apologised her medications were not synchronised on this occasion.

20. It explained it will discuss Ms G’s complaint with the team to ensure there is greater clarity around prescription schedules. It also apologised for the inconvenience and anxiety that the events caused Ms G.

21. Our Principles for Remedy says that to put things right organisations provide an apology and try to offer a remedy that returns the complainant to the position they would have been in otherwise.

22. We understand Ms G was concerned that suddenly stopping lithium could have had a harmful impact on her mental health, especially as she told us lithium had been very important in her mental health stability. Ms G did not tell us the five-day delay led her to experience a manic or depressive relapse or any other severe impact. It appears Ms G was worried about this happening as she understands the known risks of suddenly stopping lithium, which we understand would have been distressing for her.

23. Based on the information we have seen, we can see that the delay led her to experience worry, uncertainty and inconvenience for five days. We cannot see the Practice’s decision to delay providing her lithium prescription led to the more serious impact she told us she was worried could have happened.

24. Overall, we did find the Practice delayed Ms G access to her lithium medication for five days. We saw no evidence the delay led to a more severe or prolonged impact where we would consider financial remedy.

25. We are satisfied the Practice has listened to Ms G’s concerns. It has taken action to address the impact the delay caused Ms G, as it apologised and acknowledged the inconvenience and anxiety this caused her. It also says it will share her experience with staff to improve clarity around prescription schedules.

26. We are therefore reassured the Practice has understood Ms G’s complaint and will take action to better support patients with their prescriptions in the future to prevent the same thing happening again.

27. We understand Ms G’s experience caused her great distress and we are sorry to hear how the delay impacted her. We hope this statement clearly explains our decision not to consider her complaint further and gives her some reassurance that the Practice has taken her complaint seriously and addressed the impact she experienced.

1. We have carefully considered Ms G’s complaint about a GP Practice in Westminster (the Practice). Ms G has told us she was worried about the impact the delay in accessing her lithium prescription could have had on her mental health. We understand how worrying this must have been for her and we are grateful for the time she has taken to raise her concerns with us.

2. We have considered the evidence provided by Ms G and the Practice. We have seen the Practice’s decision was not in line with relevant guidelines when it decided to delay Ms G’s lithium prescription for five days in July 2024.

3. In the Practice’s response to Ms G’s complaint, it apologised for the inconvenience the events caused Ms G and apologised for the anxiety she experienced. Based on this, we consider the Practice has appropriately addressed the distress the five-day delay caused Ms G. Therefore, we will not be taking further action on this complaint. We will explain our decision in more detail below.

4. We do not underestimate the worry Ms G experienced about what could have happened because of the delay. We understand this has led her to lose trust in the Practice, which we are sorry to hear about.