South London and Maudsley NHS Foundation Trust

4. Mr K complains about the care and treatment he received from the Trust between November 2024 and January 2025. Mr K specifically complains:

• the doctor increased his dose of lamotrigine on 26 November 2024 without properly considering all of his concerns and side effects. Mr K says the doctors seemed rushed on the call.

• the Trust did not take appropriate action when he reported concerning symptoms to his previous care co-ordinator on 16 December 2024, such as arranging an urgent review with a doctor • he did not have a medication review until 15 January 2025 (initially booked for 10 January 2025) after being titrated on lamotrigine on 11 November 2024.

5. Mr K also complains about the way the Trust handled his complaint between January 2025 and May 2025. Mr K specifically complains:

• the evidence he provided was dismissed • the Trust did not address why doctors had been issuing prescriptions and increasing doses without medication reviews • the Trust refused to address questions during a meeting on 24 April 2025 when he and the advocate were challenging its previous response.

6. Mr K says that this left him feeling distressed as lamotrigine can have severe side effects and he had been told he must be closely monitored whilst being titrated. He says that he has been left without appropriate care as he has been discharged from the service and this has led to increased anxiety and suicidal thoughts.

7. He also says in relation to the meeting that took place on 24 April 2025, the Trust failed to answer the concerns raised and he feels that there was no accountability for the complaint which has made him lose trust in the service.

8. As an outcome to this complaint, Mr K is seeking thorough investigation into the Trust’s complaint process, steps to remedy the complaints process, acknowledgement of failings and a financial remedy in the range of £1,200-£3,700.

9. Mr K was titrated on lamotrigine on 11 November 2024. Titration in medicine refers to slowly increasing or adjusting the dose of a medication over days, weeks, or months to find the dose that is both effective and safe for an individual patient. This process allows healthcare providers to monitor how the body responds to the drug, reducing the risk of adverse effects and ensuring the medication works as intended.

10. Lamotrigine is a medicine used to treat epilepsy and low mood. Mr K had considered beginning the medication previously in July 2024 where he was advised by a consultant that he would be closely monitored should he decide to go ahead with the medication. He was also informed of the risks, and to report any symptoms he may have immediately due to the side effects of the medication.

11. Mr K complains that on 25 November 2024, he contacted his care co-ordinator as his first prescription of lamotrigine was nearing the end and he wanted to report the symptoms he was experiencing.

12. Mr K was contacted by a doctor the following day, however he felt the call was rushed, he was not given sufficient time to raise his concerns, and the doctor issued a new prescription increasing the dosage without addressing the need for a review. Mr K was later informed that a doctor would not be available for a medication review until 10 January 2025.

13. Mr K contacted his care co-ordinator again on 16 December 2024 to report symptoms and the following day, his care co-ordinator responded to him advising him that the doctor had booked annual leave and he could not discuss his symptoms with them. Mr K was not asked about the specifics of his concerns or provided with guidance on what to do.

14. Mr K contacted the Trust the on 17 December 2024 to speak with the duty worker who was not available, and he received a call back from his care co-ordinator. Mr K felt the care co-ordinator became defensive when he voiced his concerns about his response the previous day and so he requested to speak to a manager.

15. Mr K was assured that his concerns would be escalated to a manager, however, Mr K was not contacted. Mr K received a further email the same day asking for information about his symptoms from his care co-ordinator, although he had previously advised him to attend Accident & Emergency (A&E) if his symptoms increased. Mr K feels this was inconsistent and unprofessional communication and tells us it caused him considerable distress.

16. Mr K had his first medication review on 15 January 2025.

20. 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.

Issue 1 - the doctor increased his dose of lamotrigine on 26 November 2024 without appropriately considering his concerns and side effects. Mr K says the doctor seemed rushed on the call

21. Mr K says that on 26 November 2024, the doctor increased his dose of lamotrigine without appropriately considering his concerns and the side effects he was reporting. Mr K also says the doctor seemed rushed on the call.

22. Mr K says that this caused him distress as he had been previously advised that he should be closely monitored whilst being titrated on the medication.

23. The Trust explains in its response that the doctor did inform Mr K during the call that he would have a review on 10 December 2024. However, the doctor was not aware at this stage that his colleague, who was due to review Mr K, had booked annual leave which clashed with his appointment. The Trust apologises in its response for this error.

24. The GMC’s Good Medical Practice guidance specifies that doctors must prescribe safely following evidence-based guidance and that they should monitor or review patients appropriately. It also says doctors must propose, provide or prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs.

25. The GMC’s Good Medical Practice also says that a doctor may prescribe unlicensed or off-label medicines where necessary if they are satisfied it is in the patient’s best interest and there is sufficient evidence or experience in supporting its use. When doing this, the doctor must explain to the patient that the use is off-label and discuss the risks and benefits involved, as well as any available alternatives. The reasoning for this should be documented clearly, along with consideration of capacity and consent.

26. Our adviser explained that in this case, lamotrigine was being prescribed off-label. This means the medication is prescribed for uses not specified in its official product labelling. We understand this is common when prescribing for Emotionally Unstable Personality Disorder (EUPD).

27. We have reviewed the entry in the records from 11 November 2024. We can see evidence that Mr K was educated about the off-label use of lamotrigine and informed what it was being used for in his case. Further to this he was provided with information on the drug including prescribing, the titration process, and to report any concerns to the service.

28. Mr K was also advised to increase to 50mg of lamotrigine after two weeks if there was no rash during the consultation on 11 November 2024. We understand this proposed increase is dosage in line with the NICE BNF recommendations on the titration of lamotrigine in adults.

29. We have also reviewed the entry in the records from 26 November 2024. This entry details the call Mr K had with the doctor regarding his next prescription. It is documented that during the call, Mr K reported no side effects including a rash. It is also documented that safety netting regarding side effects was reiterated, and Mr K was advised to contact his care co-ordinator should he have any further concerns.

30. Taking all of the above into consideration, we consider the increase in dose of lamotrigine on 26 November was carried out in line with the GMC’s Good Medical Practice guidance and the NICE BNF for lamotrigine. There are indications that the doctor took Mr K’s concerns and reported side effects into consideration and considered all relevant factors before increasing Mr K’s medication.

31. With regards to Mr K’s concerns that the doctor seemed rushed on the call, we understand this must have been a distressing time for Mr K as he was concerned about the symptoms he was experiencing, and he felt we was not given the time to explain this to the doctor.

32. In situations like this, it is unlikely we would find independent evidence which would help us to reach a robust conclusion on what happened. We are unlikely to be able to say if the doctor rushed Mr K on the call, as we were not present for this conversation.

33. We have considered if we can apply a balance of probability here, by this we mean taking a view that something is more likely than not to have happened from evidence we have available or the weight we may place on some evidence. Even for us to take a view using the balance of probabilities, we would still require a strong evidence base to do so. We do not see anything to indicate that we would be able to do so here. This means that due to a lack of evidence, we are unable to form a view on what happened.

34. Whilst we cannot take a view on the manner of the doctor during this call, overall, we have not seen any indications of failings regarding the increase in dosage of lamotrigine, and we do not feel any further investigation is needed in relation to this aspect of the complaint.

Issue 2 – the Trust did not take appropriate action when he reported concerning symptoms to his previous care co-ordinator on 16 December 2024, such as arranging an urgent review with a doctor

35. Mr K says that when he contacted the Trust on 16 December 2024 to report concerning symptoms to his care co-ordinator, the care co-ordinator responded advising that the doctor was on leave and did not request further information about his concerns.

36. Mr K then called the Trust on 17 December 2024 to speak with the duty worker who was not available, and the care co-ordinator returned his call instead of the duty worker.

37. Mr K says that during the call on 17 December 2024, the care co-ordinator became defensive when he expressed his dissatisfaction with his response to his concerns. Mr K requested to speak with a manager, and says it was only then that the care co-ordinator emailed him to ask him about his symptoms later that day.

38. The Trust says in its response that the care co-ordinator feels he took Mr K’s concerns seriously by responding to his text message informing him to use the crisis line or A&E should it be required, it was also explained that a medical review had been arranged which was communicated to Mr K appropriately.

39. To assist us in considering this issue we have considered the Trust’s Care Programme Approach (CPA) policy. This policy explains that care co-ordinators are responsible for supporting the individual in line with their care plan and arranging reviews were needed. They are also responsible for advising other members of the care team of changes in the individuals circumstances which might require review or modification of their care plan.

40. In our review of the medical records, we can see when Mr K contacted the Trust on 17 December 2024, he did not provide specific details of the side effects he was experiencing. He raised concerns about the length of time until his next appointment, explaining that he wanted to discuss the symptoms he was having with a doctor. In response, the care co-ordinator explained to Mr K he had been given the earliest date available for his medication review. We cannot see that there was any exploration of the reported side effects.

41. Mr K then called the crisis line to express his concerns. We can see these concerns were passed on to his care co-ordinator, and the care co-ordinator sought advice from one of the doctors. Later that day, the care co-ordinator sent a message to Mr K to obtain more information about the side effects he was experiencing and advised Mr K to attend A&E in an emergency.

42. Our adviser explained this follow up contact should usually be a telephone call to safely and surely establish that the side effects were not urgent i.e. a rash. However, the care co-ordinator did appropriately safety net Mr K by signposting him to the crisis line or A&E, and we can see there are multiple recorded warnings given to Mr K regarding the importance of seeking medical attention for a rash prior to this contact.

43. Based on this evidence, we consider there are indications the care co-ordinator managed this contact appropriately in line with the CPA policy. The care co-ordinator managed Mr K’s level of risk and informed the doctor about the changes in Mr K’s circumstances.

44. There was no further contact until 20 December 2024 when Mr K spoke to the duty worker. The duty worker established the side effects were benign and put a plan in place for Mr K to have a medical review.

45. Mr K was then contacted by a doctor on 23 December 2024, six days after he reported his concerns. When Mr K was reviewed by the doctor on 23 December 2024, we can see that his side effects were fully explored by the doctor, and the dosage was reduced to 75mg for a slower titration. Our adviser confirmed symptoms and side effects Mr K reported in this call would not have necessitated an urgent medical review.

46. We understand this was an appropriate review in line with the GMC Good medical practice says doctors must ensure that they listen to people and respond to their preferences and concerns, that they ensure people’s physical, social, and psychological needs are assessed and responded to, and that they communicate effectively.

47. Overall, we do not see indications of failings to suggest further investigation is needed on this aspect of the complaint as Mr K was provided with a medical review when he raised concerns about his side effects and the management of his medication.

Issue 3 – Mr K did not have a medication review until 15 January 2025 (initially booked and confirmed for 10 January 2025) after being titrated on lamotrigine on 11 November 2024

48. Mr K says that he did not have a medication review until 15 January 2025 after he was titrated on lamotrigine on 11 November 2024. This caused him concern as he had previously been advised he should be closely monitored during the titration process.

49. The Trust explains in its response that it reviewed Mr K’s records and can see that whilst he was waiting for a medication review, a doctor contacted him on 23 December 2024 and was able to review his medication and reduce the dosage from 100mg to 75mg as per his request. The doctor also reiterated the crisis line and emergency service contact details if Mr K experienced any acute concerns.

50. The Trust also acknowledges and apologises in its response that Mr K’s initial medication review that was scheduled for 10 January 2025 was rearranged for 15 January 2025 due to staff sickness. The review then took place virtually on 15 January 2025.

51. When reviewing this part of the complaint, we have considered the GMC’s Good Medical Practice guidance on monitoring and reviewing medication, as outlined in point 24 of this statement. In addition to what is outlined above, the guidance also says doctors should take account of patients’ needs, and any risks arising from the medicines they are prescribed.

52. Whilst there is no specific guidance on how soon a medication review should occur after initiation in Mr K’s circumstances, our adviser confirmed the out-patient follow up appointment with the doctor (which was around six weeks after initiation) was an appropriate timescale for review when considering the responsibilities outlined in the GMC’s guidance. We understand this timescale would allow for the initial adjustment period where the dosage is built up so that the doctor could review Mr K’s response to lamotrigine and determine if further dose alteration was needed.

53. We also understand that there were no indications Mr K required an urgent medical review during this period and as we have detailed earlier in this statement, we consider the care Mr K received between beginning lamotrigine in November 2024 and his medication review in January 2025 was responsive to his needs and in line with the relevant guidance.

54. We can also see that by the appointment on 15 January, Mr K’s physical side effects had eased and were reportedly no longer an issue, and that Mr K had reported some mental health benefits.

55. Despite this, we recognise the Trust could have contacted Mr K sooner to provide reassurance about the timescale for the review given his concerns about his side effects. We consider this was a shortcoming, rather than a service failure, as Mr K was reviewed in December when he raised concerns with the duty team and doctor and reassured about his dosage and the care plan.

56. Overall, we do not see indications of failings to suggest further investigations are needed on this aspect of the complaint.

Issue 4 – Mr K is also unhappy with the way the Trust handled his complaint between January 2025 and May 2025. Mr K says that the evidence he provided was dismissed, and the Trust did not address why doctors had been issuing prescriptions and increasing doses without medication reviews

57. Mr K says that he is also unhappy with the way the Trust handled his complaint between January 2025 and May 2025. Mr K says that the images of messages from his care co-ordinator that he provided as evidence to the Trust were dismissed, and he feels that it did not address the concerns he raised in relation to doctors issuing prescriptions and increasing the dosage of his medication without a review.

58. Our ‘Complaint standards’ say staff should actively listen and demonstrate a clear understanding of what the main issues are for the person who has made the complaint, and the outcomes they seek. In addition to this, the standards say organisations should take a thorough, proportionate and balanced look into the issues raised in a complaint. This means they should give due consideration to evidence submitted by those raising concerns.

59. We can see that the Trust’s response to the complaint explains the timeline of Mr K’s contact with his care co-ordinator and the wider team. This includes Trust the care co-ordinator’s reply to Mr K’s text message on 17 December 2024 informing him about the arrangements for his medical review and within this it acknowledges the evidence Mr K provided. The response also addresses the issue around the delayed medical review due to the doctor’s annual leave and provides an apology for this.

60. We consider the Trust has provided a proportionate and balanced response to Mr K’s complaint, and that it has explained the process followed when issuing his prescription and increasing his medication dosage.

61. We are also satisfied that the Trust has taken Mr K’s evidence into account when investigating his complaint, as it is evident from the response that it has considered the information Mr K provided.

62. Overall, we do not see any indications of failings to suggest further investigation is needed for this aspect of the complaint. This is because we consider the Trust has addressed the concerns Mr K raised in a proportionate way in line with our complaint standards.

63. We appreciate that the Trust’s response does not explain the reasoning for the increase in dosage in as much detail as Mr K would have preferred. We hope the explanations that we have provided in this statement provides Mr K with a further understanding of the dosage increases.

Issue 5 – Mr K says that the Trust refused to address questions during a meeting on 24 April 2025 when he and the advocate were challenging its previous response

64. Mr K says that the Trust refused to answer questions during a local resolution meeting on 24 April 2025 when he and the advocate were challenging the Trust’s first response.

65. We can see that the Trust has provided a follow up letter to Mr K from the meeting on 24 April 2025 which acknowledges Mr K’s dissatisfaction of the complaint handling. In this letter it explains that it will not reinvestigate concerns that have already been addressed.

66. In situations like this, it is unlikely we would find independent evidence which would help us to reach a robust conclusion on what happened. We are unlikely to be able to say if the Trust refused to answer questions during the meeting on 24 April 2025 as we were not present.

67. We have considered if we can apply a balance of probability here. Even for us to take a view using the balance of probabilities, we would still require a strong evidence base to do so. We do not see anything to indicate that we would be able to do so here.

68. Whilst we cannot take a view on what happened in the meeting, as outlined in the previous section of this statement we are satisfied there are indications the Trust responded to Mr K’s complaint in line with the NHS Complaint Standards in its written responses. We would not expect the Trust to reinvestigate concerns that have already been addressed proportionately and in line with these standards.

69. Overall, we do not see indications of failings to suggest further investigation is needed on this aspect of the complaint.

Conclusion

69. We will not be taking any further action on Mr K’s complaint. We recognise the significant concern and distress these events have caused Mr K. We hope our consideration provides Mr K some reassurance that his concerns have been carefully and independently considered.

1. We have carefully considered Mr K’s complaint about South London and Maudsley NHS Foundation Trust (the Trust) in relation to the care and treatment he received from the primary care mental health team.

2. We want to reassure Mr K that we have fully considered the circumstances and the impact that it has had on him. We hope that this statement offers reassurance that his experience matters.

3. Having reviewed all the evidence, we have seen no indication that anything went seriously wrong. We therefore do not see any indications to suggest further investigation is needed. We will explain our reasons for our decision in this statement.