Dorset Healthcare University NHS Foundation Trust

4. Mr T complains on behalf of his wife, Mrs T, about aspects of care and treatment Mrs T received from the Trust in March 2025. Specifically, he complains the Trust:

• failed to discuss her diagnosis with her • inappropriately suggested Mrs T’s GP lower the dosage of her medication and • failed to explain how it reached its diagnosis.

5. Mrs T says she feels confused, un-worthy, worried, depressed, and anxious for the future.

6. As an outcome to the complaint, Mr T is seeking an apology and evidence of service improvements.

7. Mrs T’s GP sent an urgent referral on her behalf to Weymouth and Portland CMHT on March 2025.

8. The timescale for responding to urgent referrals is 5 working days.

9. A community mental health nurse (CMHN) contacted Mrs T via telephone where Mrs T confirmed her symptoms. Mrs T explained to the CMHN that after receiving a response from the government, to which she had recently written letters, she questions her behaviours and actions.

10. Mrs T further stated she was unaware of available options/services to offer support if she is not open to a CMHT and so the CMHN shared details of the Retreat, Connections, Community Front Rooms. Mrs T was informed her referral would be discussed and she would be updated regarding the outcome.

11. The Trust’s consultant psychiatrist reviewed Mrs T’s contact with the CMHN and dictated the discharge summary letter later the same day and this was sent to Mrs T on 14 March 2025.

Failure to discuss diagnosis

15. To decide if we should conduct a detailed investigation into a complaint, we first consider whether there are any indications something went wrong with the service provided by the organisation. If so, we then explore if the organisation would be willing to take further steps to put this right and resolve the complaint.

16. Mrs T received a discharge letter from the Trust dated 14 March 2025. Mrs T says the Trust failed to discuss the diagnosis it had reached in relation to her mental health. The records show Mrs T had history of possible borderline personality disorder.

17. In its initial response of 28 March 2025, the Trust explained there was not enough clinical reasoning to offer Mrs T a face-to-face appointment. It confirmed it had reached a conclusion following Mrs T’s review with the community mental health nurse (CMHN) on duty. The review recorded Mrs T was no longer experiencing any episodes and was mindful of her actions and behaviours. its initial response of 28 March 2025, The Trust explained there was not enough clinical reasoning to offer Mrs T a face-to-face appointment. It confirmed it had reached this conclusion due to Mrs T having been reviewed by the CMHN on duty and the outcome of that review being that Mrs T was no longer experiencing any episodes and was mindful of her actions and behaviours and also due to no potential medication changes being suggested, other than advice to Mrs T’s GP to gradually reduce the dose of Quetiapine.

18. NICE guidelines QS88( statement 1) explains that people with possible borderline or antisocial personality disorder should have a structured assessment by a specialist in mental health before diagnosis is given .

19. Bi-polar disorder guidance CG185 sets out that assessment should include a full psychiatric assessment and should consider differential diagnoses including personality disorder.

20. Our clinical adviser explained that the comment of “underlying personality traits have played a significant role in her presentation” appears to be a clinical impression based on a review of the notes and not a diagnosis given.

21. The evidence we have, including NICE guidelines QS88 and bipolar disorder guidance CG185, shows a psychiatric assessment was necessary, and not carrying one out indicates a failure.

22. During our primary investigation process, we approached the Trust to discuss our findings. The Trust acknowledged it did not complete a full assessment and as such its service on this occasion fell below NICE clinical guidelines. In light of our findings, we asked the Trust if it would be willing to provide an apology and make service improvements. The Trust agreed it would.

23. We approached Mr T and explained the Trust was willing to take steps to resolve his complaint. He was happy with this and confirmed the apology and evidence of service improvements would resolve his complaint.

24. Our NHS complaints standards say organisations should find ‘suitable and appropriate ways to put things right for people who raise a complaint.’ In this case, we are satisfied the Trust will apologise and provide evidence of service improvements. As this is the outcome Mrs T is seeking, we consider this will resolve her complaint, so we do not need to take any further action.

Quetiapine

25. Mr T says the consultant psychiatrist’s discharge letter dated 14 March 2025, suggested a reduction in her medication, Quetiapine. Quetiapine treats several mental health conditions, including schizophrenia, bipolar disorder (mania and depression), and depression when combined with other medicines. It also helps prevent future episodes of mania and depression in people with bipolar disorder.

26. In its response, the Trust explained Mrs T suffers from a type 2 diagnosis. A type 2 diagnosis is a milder form of mood fluctuations without full manic episodes which are associated with bipolar type 1.

27. The Trust explained this is important when weighing up the risks and benefits of prescribing Quetiapine. This is because Quetiapine is one of the antipsychotics “with greatest propensity to affect heart rhythm” and thus the Trust felt it important to address this matter “especially when Mrs T has cardiac disease, problems with heart rhythm and a pacemaker.” The Trust acknowledged this was not explained in its discharge letter.

28. NICE guideline CG185 says a clinician who wants to stop a patient taking an antipsychotic such as quetiapine should reduce the dose gradually over at least four weeks to minimise the risk of relapse.

29. NICE guidelines NG215 emphasises shared decision-making, regular review, clinical assessment, and planning before withdrawal.

30. The GMC good medical practice (domain 2) says doctors are required to work in partnership with patients, give patients the information they want or need in a way they can understand and share information about their condition, its likely progression and treatment options, including risk and uncertainties.

31. NICE guidance on shared decision making (NG197) states clinicians should discuss significant diagnostic or treatment decisions with the patient and allow sufficient time for questions. It requires clinicians to explain the nature of the condition, outline the available treatment options, and clearly set out the reasons for their recommendations.

32. Our adviser says the records suggest the psychiatrist did not follow NICE guideline NG215, the GMC’s Good Medical Practice (domain 2) and NICE guideline NG197, as it did not involve Mrs T in shared decision-making, did not work in partnership with her, and did not discuss the treatment decision with her.

33. Accordingly, we consider a diagnostic assessment should have been conducted, given the consultant psychiatrist was making recommendations for an antipsychotic medication to be reduced and eventually stopped. We consider the psychiatrist’s decision to reduce quetiapine and eventually stop it use by Mrs T without an assessment or involving her in the decision making is not in line with NICE guidelines NG215, the GMC good medical practice (domain 2) and NICE guidelines NG197 . We consider this to be an indication of failing.

34. During our primary investigation process, we approached the Trust to discuss our findings. The Trust acknowledged it did not include Mrs T in discussions and as such its service on this occasion fell below NICE clinical guidelines. In light of our findings, we asked the Trust if it would be willing to provide an apology and make service improvements. The Trust agreed it would.

35. We approached Mr T and explained the Trust was willing to take steps to resolve his complaint. He was happy with this and confirmed the apology and evidence of service improvements would resolve his complaint.

36. Our NHS complaints standards say organisations should find ‘suitable and appropriate ways to put things right for people who raise a complaint.’ In this case, we are satisfied the Trust will apologise and provide evidence of service improvements. As this is the outcome Mrs T is seeking, we consider this will resolve her complaint, so we do not need to take any further action.

Clinical Impression

37. In our initial call with Mr T in October 2025, he explained that the consultant psychiatrist did not explain his decision regarding Mrs T’s symptoms.

38. In its final response on 6 May 2025, the Trust acknowledged it had not clearly explained the reasoning behind its decision and said it had learned the importance of doing so during discharge process and in clinic letters.

39. The NICE guideline on personality disorder (CG78) promotes a person-centred approach. It recommends clearly explaining the diagnosis, what it means, and the available treatment options, while also being mindful of the potential impact of diagnostic labels.

40. We have seen no evidence to suggest the Trust discussed its clinical diagnosis with Mrs T.

41. During our primary investigation process, we approached the Trust to discuss our findings. The Trust acknowledged it did not include Mrs T in discussions and as such its service on this occasion fell below NICE clinical guidelines. In light of our findings, we asked the Trust if it would be willing to provide an apology and make service improvements. The Trust agreed it would.

42. We approached Mr T and explained the Trust was willing to take steps to resolve his complaint. He was happy with this and confirmed the apology and evidence of service improvement would resolve his complaint.

43. Our NHS complaints standards say organisations should find ‘suitable and appropriate ways to put things right for people who raise a complaint.’

44. In this case, we are satisfied the Trust has acknowledged it did not provide appropriate care and treatment and is willing to apologise and provide evidence of service improvement. As this is the outcome Mr T is seeking, we consider this will resolve his complaint, so we do not need to take any further action on the complaint.

45. The Trust has advised it will respond to Mr and Mrs T by 06 March 2026.

1. We have carefully considered Mr T’s complaint about Dorset Healthcare University NHS Foundation Trust (the Trust) on behalf of his partner, Mrs T. We are sorry to hear how Mr and Mrs T have been affected by aspects of care and treatment Mrs T received from the Community Mental Health Team (CMHT) at the Trust in March 2025.

2. We consider the Trust failed to discuss Mrs T’s diagnosis with her and failed to explain how it reached its diagnosis. We found the Trust inappropriately advised Mrs T’s GP to lower the dosage of her medication and eventually stop it. We will explain our decision in more details below.

3. The Trust confirmed it would apologise to both Mr and Mrs T and provide evidence of service improvements. Mr T has accepted this offer to resolve his complaint, so we have decided not to take any further action on his complaint.