A practice in the Arun area

5. Mr A complains about the care and treatment provided by the Practice in March and April 2024. Specifically, he says the Practice:

• prescribed 200mg of promethazine hydrochloride for six weeks with no psychiatric oversight or appropriate risk monitoring • prescribed diazepam inconsistently and stopped abruptly • failed to raise a safeguarding concern or mental health review • publicly removed him from the Practice in retaliation for complaining about the Practice Manager • failed to provide reasonable adjustments prior to removing him from the Practice • assigned him to a Practice where he had recently applied for a job • failed to provide continuity of care or discharge planning following his removal • withdrew propranolol prescription following transfer to new Practice.

6. As a result of being prescribed 200mg of promethazine hydrochloride for six weeks Mr A says he was hospitalised with tachycardia (a heart rate of over 100 beats per minute) during a period of acute crisis and suicidal idealisation.

7. Mr A told us the unsafe prescribing led to multiple overdoses and attendances at the Emergency Department.

8. Mr A tells us being publicly removed from the Practice was retraumatising and humiliating. He says he was placed on the NHS Special Allocations Scheme during a mental health crisis and prior to a planned psychiatric review. He says he was denied safe access to care during an active breakdown.

9. Mr A seeks an apology acknowledging the impact of the claimed failings and service improvements.

10. Mr A (33) had sadly recently been the victim of assault. He was suffering with poor mental health and suicidal thoughts and disclosed this to the Practice on 9 February 2024. The Practice prescribed medications to help Mr A during a time of crisis and referred him to secondary mental health services for additional support. Mr A’s relationship with the Practice broke down and he was removed from its register on 26 April 2024.

Promethazine

14. Mr A told us between February and May 2024 the Practice prescribed 200mg promethazine per day with no psychiatric oversight or monitoring.

15. We reviewed this issue with the help of our GP adviser using Mr A’s medical records.

16. Promethazine is a sedating antihistamine used to treat various conditions including allergies, motion sickness and nausea. It can also be used as a sedative or sleep aid.

17. The British National Formulary (BNF) states the maximum daily dose of promethazine for adults is 25 to 50 mg.

18. The Practice first prescribed promethazine on 29 February 2024. Between this date and 22 May 2024, the Practice prescribed Mr A promethazine 25mg, with instructions to take one to four times a day on eleven occasions. The majority of these prescriptions were for 28 tablets with one prescription on 5 April being for 56 tablets.

19. Promethazine can be purchased over the counter at a maximum dose of 25mg. Our GP adviser told us it makes sense where patients are prescribed medication at a higher dose such as in Mr A’s case that monitoring is done in the form of patient follow-up to assess benefits and side effects.

20. Our GP adviser told us following initiation of an acute medication for mental health issues the patient should be offered routine appointments to assess clinical progress but there is no stipulated timeframe for this.

21. Mr A had a telephone consultation with the Practice on 5 March shortly after promethazine was first prescribed. He reported feeling optimistic and the Practice documented he was calmer.

22. There are no specific guidelines for monitoring patients taking promethazine. In certain specific groups such as the elderly or patients on other medications that can affect the heart, then it is sensible to consider whether an electrocardiogram (ECG) is needed, or blood tests to check kidney and liver function.

23. Mr A had a blood test on 1 March which showed no issues with his liver or kidney function. We also saw evidence the Practice booked a blood test and ECG for Mr A on 12 April to take place on 29 April and 7 May respectively. The Practice sent a text message to Mr A to advise him of the appointments. It is not clear if Mr A attended these appointments.

24. Our GP adviser said the frequency of requests for promethazine should have alerted the Practice Mr A was using promethazine at its maximum prescribed dose. 28 tablets were only lasting seven days and therefore Mr A was taking four tablets per day which is equal to 200mg promethazine.

25. We consider the Practice did not prescribe promethazine in accordance with BNF guidance.

26. Mr A raised this issue with the General Medical Council (GMC). We contacted the GMC for further details. It told us a triage assistant registrar (a senior decision maker) noted the complaint was concerning a single prescribing error with no other information suggestive of a persistent pattern of prescribing issues.

27. The GMC told us the assistant registrar also noted the prescribing GP had sought guidance on the issue when it was raised, acknowledged the error and apologised for it. The prescribing GP also sought to find a practitioner Mr A felt safe with so he could continue to engage with clinicians and receive medical treatment. It said, therefore the matter did not appear to raise serious concerns about patient safety.

28. The assistant registrar considered it appropriate to write to the prescribing GP and their responsible officer (a designated professional who has the responsibility of overseeing the GP and ensuring they maintain the required standards of medical practice) to provide them with a copy of the complaint. This was so it could be discussed with the prescribing GP and form part of the prescribing GP’s next appraisal and revalidation process to be learned from and reflected upon.

29. The GP completed a structured reflective document specifically for the incorrect prescribing of promethazine on 3 July 2024 (this process allows doctors to demonstrate with confidence to their responsible officer they are safe, up to date and fit to practise). This document outlines the GP’s reflection, changes they made to their practice and the learning they took.

30. As an outcome to his complaint Mr A would like an apology and service improvements. The Practice has already written to Mr A apologising for the distress caused by this matter. We are satisfied the action taken by the prescribing GP following input by the GMC is sufficient to remedy this part of Mr A’s complaint.

Diazepam

31. Mr A told us during the period February to April 2024 the Practice prescribed diazepam inconsistently. He says the GP acknowledged this was highly risky, yet prescriptions were issued and then stopped abruptly when the Assessment and Treatment Service (ATS) took over his care.

32. ATS is the entry point into adult specialist mental health services. It brings together local NHS mental health services, GP Practices and community organisations to offer joined up mental health support.

33. We reviewed this issue with the help of our GP adviser using Mr A’s medical records.

34. Diazepam is a benzodiazepine (a class of medications that act as depressants, used for sedation and anxiety relief). The BNF recommended adult dose is maximum 10mg three times daily (total dose maximum 30mg per day).

35. NICE guidance for generalised anxiety disorder advises acute short term prescriptions only in small quantities to help a patient through a crisis.

36. Mr A contacted the Practice on 5 February and reported he was in a mental health crisis. The Practice arranged a same day face to face appointment, but Mr A left the Practice without being seen when he realised the appointment was not with his preferred GP.

37. Mr A’s preferred GP contacted him the following day to explain the triage team felt Mr A needed to be seen by a clinician that day as he was in such distress. Mr A was dealing with some difficult life events which were affecting his mental health.

38. The GP arranged a face to face appointment for Mr A that evening which Mr A did not attend. The GP prescribed a fourteen day course of diazepam 5mg once daily and advised Mr A by text message the prescription had been issued.

39. Mr A had a telephone consultation on 15 February and requested a further prescription of diazepam. Mr A reported taking recreational drugs in large quantities. The Practice had a long discussion with Mr A about the risks of taking diazepam with duloxetine (a medication already prescribed to Mr A to alleviate depression and anxiety) especially in the context of recreational drug use. Mr A terminated the call and did not answer when the Practice tried to call back.

40. Mr A contacted the Practice on 16 February and reported he had terminated the call the previous day as he did not like the way he was being spoken to. He said the GP he was talking to was not willing to prescribe diazepam and he wanted to speak to his preferred GP who he felt had a sense of compassion and understanding.

41. The Practice carried out a medication review on 16 February. Mr A reported feeling hopeless. He wanted diazepam to help him cope over the weekend. The Practice prescribed a five day course of diazepam 5mg once daily.

42. On 24 February Mr A had a telephone consultation with his preferred GP. Mr A reported spiralling out of control. The GP urgently referred Mr A to ATS and signed him off work. The GP prescribed a fourteen day course of diazepam 5mg once daily.

43. ATS contacted Mr A and arranged an appointment for 27 February. Mr A contacted the Practice that day and reported there had been an issue during his ATS assessment as the room had been double booked, and this meant his appointment was cut short. Mr A said he ‘lost it badly’. He said he wanted to be referred to the crisis team.

44. ATS wrote to the Practice summarising Mr A’s appointment. The letter says Mr A was very intimidating and hostile during the appointment, and staff were unable to complete the assessment. It said Mr A was unable to engage in care planning, he became upset and walked out of the appointment. ATS later attempted to engage with Mr A over the phone, but he declined the offer of a referral to the crisis team.

45. The Practice contacted Mr A on 27 February. The records document Mr A was extremely heightened and difficult to engage with. The Practice called the crisis team to arrange an assessment.

46. Mr A contacted the Practice on 5 March as he wanted to discuss a plan going forward with his GP. Mr A reported he was not taking diazepam and that he had overdosed on propranolol five days earlier.

47. Mr A’s preferred GP called him later that day. The Practice prescribed promethazine noting Mr A was already taking duloxetine and propranolol. The GP noted Mr A was quite calm and feeling more optimistic. Mr A advised he was not feeling suicidal, and his mum would look after his medication.

48. On 2 April the Practice referred Mr A to ATS having discussed with Mr A his need for a diagnosis and treatment to prevent future crises.

49. On 24 April Mr A contacted the Practice and spoke to a clinical pharmacist. Mr A asked to be prescribed diazepam. The pharmacist advised they were unable to provide a repeat prescription and passed the request to a GP.

50. On 26 April the Practice prescribed 14 tablets of diazepam 2mg with instructions to take maximum three times per day. This was the same day the Practice requested removal of Mr A from its register.

51. On 1 May the Practice prescribed 14 tablets of diazepam 2mg. On 16 May Mr A was prescribed a further course of 14 diazepam 2mg tablets. Mr A’s care was transferred to the SAS Practice on 16 May.

52. The diazepam prescriptions provided by the Practice are within the BNF recommended maximum dose for an adult. Mr A was already on the maximum dose of duloxetine at the time and there was no scope to increase this medication. Small doses of diazepam in this context of a crisis was therefore appropriate.

53. We saw no evidence the Practice stopped prescribing diazepam abruptly. Our GP adviser told us the dose and frequency of which Mr A took diazepam did not warrant a gradual reduction.

54. We recognise Mr A was going through a very difficult time. We consider the Practice appropriately prescribed diazepam to Mr A in small doses when he was in crisis in accordance with NICE guidance. We have seen no indication of a failing here.

Safeguarding and mental health review

55. Mr A says he disclosed a sexual assault, suicidal ideation, and acute psychological distress to the Practice between March and April 2024. He said no safeguarding referral or mental health review was made.

56. Mr A says the practice relies on the fact the ambulance service had already made a safeguarding referral to argue safeguarding was addressed. He says his disclosure of rape, suicidality and acute PTSD were made directly to the Practice between March and April 2024 and believes its failure to escalate his concerns is a failing in professional safeguarding responsibility.

57. We reviewed this issue with the help of our GP adviser using Mr A’s medical records.

58. On 1 March the ambulance service spoke to Mr A on the phone. Mr A reported regularly taking more than his prescription and has thoughts of taking his own life. He said he had been recently assaulted by an abusive ex-partner.

59. The ambulance service made a safeguarding referral the same day and the outcome was communicated to the Practice on 6 March. The safeguarding team emailed the Practice with the details of the safeguarding referral stating the concern raised by the ambulance service had not resulted in a safeguarding enquiry under section 42 of the Care Act 2014. The safeguarding team advised the Practice to continue to provide support to Mr A.

60. The records show Mr A was engaging regularly with the Practice. The Practice appropriately referred Mr A to secondary care for mental health review and prescribed appropriate medication. These actions are in accordance with GMC’s Good Medical Practice which says, ‘if you assess, diagnose or treat patients, you must refer a patient to another practitioner when this serves the patient’s needs’.

61. The guidance also says, ‘in providing clinical care you must prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patients health and are satisfied that the drugs or treatment serve the patients’ needs’.

62. Mr A was aware of the different services available and was able to independently contact them. The records also suggest Mr A was supported by his mother who advocated for him and was monitoring his medication.

63. Mr A did not report any new incidences of abuse that would have triggered another safeguarding referral, therefore there was no reason for a safeguarding referral to be repeated. We have seen no indications of failings. We consider the Practice were aware a safeguarding referral had already been made and were following instructions to continue to support Mr A in the primary care setting.

Removal

64. Mr A says the Practice publicly removed him from its register in retaliation for complaining about the Practice Manager.

65. NHS England guidance for removal of patients says a patient can be removed from the practice immediately and without warning if a patient has threatened violence and the police have been contacted. The patient will be allocated a new practice under the Special Allocation Scheme (SAS).

66. The SAS is a process within the NHS allowing GP Practices to remove patients from its register if the patient exhibits aggressive or violent behaviour. This process ensures the patient can still access healthcare services in a secure environment. The SAS is designed to protect staff and patients from the risk of violence and to maintain a safe environment for all.

67. On 22 April 2024 the GP records document Mr A displayed threatening behaviour on the premises of the Practice. The records say he became very angry, slapping the desk and shouting profanities as he walked out. This behaviour was followed up with an email from Mr A to the Practice on 25 April threatening physical violence towards specific members of Practice staff.

68. The Practice reported the violent behaviour to the police and filled out a request form to immediately remove Mr A from the Practice.

69. The form requires the Practice to describe the incident which had been reported to the police. The Practice wrote, ‘patient behaviour has escalated recently, with an unannounced visit to the Practice on 22 April which resulted in patient verbally abusing staff. Patient has now contacted the Practice via the website with threats of violence to staff members’.

70. The form asks about any other relevant information. The Practice wrote, ‘ongoing issues with the patient over the last three or four months. We believe patient has made complaints about our service to the Ombudsman, CQC and NHS England. Other threats of speaking to the papers etc.’

71. The Practice sent Mr A a letter on 26 April explaining he had been immediately removed from the Practice.

72. The ICB authorised the Practice’s request as a valid immediate removal and NHS England sent a letter to Mr A on 29 April advising he had been allocated a new Practice under the SAS. This letter informed him of his right to appeal the removal.

73. We saw the Practice requested immediate removal of Mr A from its register following his threatening and violent behaviour which was reported to the police. We recognise the removal form also mentions Mr A had made complaints about the Practice however, this was not the reason for removing him from its register.

74. While we recognise the distress Mr A has told us this matter caused, we consider the Practice acted in accordance with guidance when requesting the removal of Mr A.

Reasonable adjustments

75. Mr A told us the Practice failed to provide reasonable adjustments. He says the Practice did not consider his mental health crisis when making the decision to remove him.

76. We reviewed this issue with the help of our GP adviser using Mr A’s medical records.

77. NHS England says, ‘if you support someone with a physical or mental impairment that has a substantial and long-term adverse effect on their ability to do normal activities, please make sure they have access to good healthcare. You can do this by making changes, often quite small, to the way you care for people. These changes are called reasonable adjustments and can be things like:

• making sure there is good access for people who use wheelchairs • giving someone a priority appointment if they find it difficult waiting in their GP practice or hospital • offering a longer appointment if a patient needs more time with a doctor or nurse to make sure they understand the information they are given • having a quiet space available for people waiting for their appointment.

78. Our GP adviser told us it is important to consider what Mr A’s reasonable needs were. Unrealistic patient expectation is a valid reason in itself to consider removing a patient from the practice register. There is a ceiling to what service can safely and reasonably be delivered in primary care, while maintaining staff and other patient safety.

79. GMC’s Good Medical Practice asks, ‘when might it be necessary to end a relationship?’ It says, ‘in rare circumstances, the breakdown of trust between you and a patient means you can’t continue to provide them with good clinical care. This might occur when a patient has for example:

• been violent, abusive, or made threats to you or a colleague • displayed other criminal behaviour, such as stealing • persistently acted unreasonably.

80. The Practice was aware of Mr A’s needs and had made a plan on 24 February 2024 in response to this. Mr A’s records state, ‘mental health crisis. [Mr A’s preferred GP] will make contact next working day if in a crisis or offer same day GP or mental health support’.

81. Mr A was repeatedly offered appointments with the GP of his choice to allow continuity of care with a GP he liked and believed helped him. This meant he was known and understood by a GP who advocated on his behalf with other services.

82. During the period complained about there was regular, almost daily contact with the Practice from Mr A or with other services regarding Mr A’s care. Mr A was consistently offered flexibility for his appointments including telephone or face to face, and longer appointments.

83. It is clear from 22 April when Mr A’s behaviour escalated, the professional relationship had broken down. It would not be reasonable to expect the Practice to continue to provide primary care services to Mr A in these circumstances.

84. We have seen evidence the Practice was aware of Mr A’s mental health crisis and had been providing reasonable adjustments to ensure he received continuity of care. The Practice reached a point where it could no longer safely provide care to Mr A. Mr A’s abusive and violent behaviour was the reason for his removal.

85. In line with GMC guidance, it was appropriate to remove Mr A from the Practice register.

Assignment of new practice

86. Mr A said he informed the Practice on 12 April 2024 he had applied for the Practice Manager role at another local Practice. He said following his removal, he was assigned to this particular local Practice as his SAS practice.

87. Information from Primary Care Support England about the process for SAS allocation says, ‘patients who are removed from their GP Practice due to an incident at the practice requiring police action are allocated to a specific GP Practice who manage SAS patients. The patient is notified by letter that they have been placed on the scheme and are given contact details of the practice. The Practice who has requested the removal will receive an acknowledgement that the removal has been completed’.

88. Once the Practice requesting removal has submitted the removal form to Primary Care Support England, the SAS allocation process is carried out by PCSE. The removing practice has no input into which practice is allocated to the removed patient.

89. We contacted PCSE for confirmation of this, it told us it has a ‘list of practices who have signed up to provide the Special Allocation Scheme services, and we allocate patients to these practices by area or by closest practice to the patient address, depending on what the ICB has previously advised’.

90. We have seen nothing to suggest the Practice had any involvement in deciding which SAS Practice Mr A was allocated following his removal. We will take no further action on this part of the complaint.

Continuity of care and propranolol

91. Mr A said the Practice failed to provide continuity of care or discharge planning following his removal from the Practice. He said propranolol was withdrawn without re-prescription. Mr A told us this demonstrated an unsafe and failed handover of care.

92. We reviewed this issue with the help of our GP adviser using Mr A’s medical records.

93. GMC guidance for ending a professional relationship with a patient states, ‘you must:

• tell the patient or arrange for the patient to be told of your decision and the reasons for it, where practical this should be done in writing • consult and follow relevant local guidance and regulations • make sure arrangements are in place for the continuing care of the patient if they are unable to make arrangements for themselves

94. Our GP adviser told us it is good practice to inform the patient directly of their removal and to inform the patient NHS England will notify them regarding their future care provider. We can see the Practice informed Mr A of his removal on 26 April and NHS England advised him about his future care arrangements on 29 April.

95. Mr A was receiving regular prescriptions at the time of his removal including a prescription for propranolol. The propranolol prescription was for 14 tablets with advice to take one per day or increase to two per day if needed.

96. Mr A received prescriptions for propranolol on 5 March, 24 April, 1 May, 8 May and 15 May by which time his care and been transferred to the SAS Practice. We have seen nothing to suggest Mr A was ever without access to primary care services or prescribed medication as a result of the transfer to the SAS practice.

97. We consider the Practice acted in accordance with GMC guidance with regard to the transfer of Mr A’s care.

Summary

98. We understand our decision may be disappointing for Mr A and we hope our report goes some way to reassuring him about the care and treatment he received.

1. We have carefully considered Mr A’s complaint about the Practice. We acknowledge how important Mr A’s complaint is to him and we are sorry to hear of the difficult time he has had.

2. We have reviewed aspects of Mr A’s care and treatment. For Mr A’s complaint about promethazine prescribing, we have decided the Practice has already done enough to remedy this part of the complaint.

3. For the rest of Mr A’s complaint we do not consider anything went seriously wrong.

4. We have therefore decided we do not need to take any further action on the complaint. We understand our decision may be disappointing to Mr A and we are sorry if this adds any further distress at an already challenging time.