A practice in the Trafford area

3. Miss D complains that the GP Practice inappropriately prescribed her codeine medication in October and November 2022.

4. Miss D believes she should not have been prescribed codeine because of her liver disease and says that the codeine resulted in her having psychosis in December 2022, that in turn led to her being sectioned under the mental health act and admitted to hospital.

5. Miss D says the experience was very distressing and upsetting for her and has impacted on her mental health.

6. Miss D is seeking apologies and acknowledgement that codeine should not have been prescribed. She is also seeking financial redress.

7. Miss D was discharged from hospital in July 2022 after being treated for decompensated liver disease. Miss D saw a GP on 6 October when she described aching/painful arms and legs. She was prescribed codeine for the pain with further prescriptions later in October, when she reported that the codeine was helping with the pain, and in November.

8. On 16 December Miss D was found by the police in an agitated state in a shopping centre. The police detained Miss D under section 136 of the Mental Health Act (this allows the police to detain people who may be suffering from a mental disorder), and she was taken to the hospital emergency department.

9. On 17 December’s Miss D’s alcohol level was recorded as undetectable and she had a mental health review. At this review it was recorded that Miss D had stopped taking her codeine tablets suddenly about three days ago and the mental health review said that she was experiencing withdrawal from codeine.

10. The mental health team saw Miss D again on 18 December and her mental capacity was reviewed on 19 December. Miss D was detained under the Mental Health Act and on 21 December and admitted to Greater Manchester Mental Health Foundation Trust mental health services. Miss D was discharged on 31 December and seen by the home-based mental health treatment team on 1 January, with further contact from the same team by telephone on 4 January.

11. The GP Practice responded to Miss D’s concerns in its complaint response and explained the reasoning behind the codeine prescriptions.

16. Miss D first saw her GP on 6 October 2022 when the GP recorded pain in Miss D’s arms and legs, particularly at night, and she was prescribed codeine. The relevant guidance here for how pain such as Miss D’s should be dealt with, is NICE CKS Analgesia, mild to moderate pain. This guidance says that paracetamol is usually the first line choice for mild to moderate pain, although anti-inflammatory drugs such as ibuprofen and naproxen may be preferable. This guidance goes on to say that codeine may be used where first line options have not been effective. However, this guidance also says that codeine should not be prescribed to people with liver disease.

17. Miss D had liver disease secondary to her alcohol use. Our GP Adviser has explained that pain relief for patients with liver disease can be difficult as all medications have an increased risk compared to patients without liver disease.

18. Regardless of this difficulty in prescribing, the relevant guidance recommends paracetamol as the first line and specifically that codeine should not be prescribed. The actions of the GP Practice here were not in line with the relevant guidance and indicate failings in its processes.

19. Miss D has said that the prescribing of codeine was the cause of her hospital admission in December.

20. Our psychiatry adviser has explained that during the period Miss D was prescribed codeine, October to December, there is no evidence of Miss D’s mental health deteriorating. When Miss D was admitted to hospital in December, it was recorded that she had decided to stop taking her codeine medication suddenly, about three days previously. The medical records for Miss D’s emergency stay and her admission in the mental health unit, both recorded that it was likely Miss D was suffering from codeine withdrawal as a result of stopping the medication suddenly. Having read the records for this inpatient period and Miss D’s account of the events, it is clear this was a very upsetting and difficult time for her.

21. Delerium and/or psychosis after withdrawal from opioids are recognised issues and our psychiatry adviser has referenced a recent relevant medical paper which has studied these points as set out in the evidence section above. Our psychiatry adviser has reviewed Miss D’s records to understand her previous mental health and commented that there is no evidence she had delirium or psychotic symptoms leading to a previous admission to mental health services, although she had experienced psychotic type symptoms such as paranoia, persecutory delusions and multiple hallucinations for around 2-5 years.

22. The patient information leaflet issued with the codeine medication advises patients not to stop taking the medication suddenly. We cannot say with any certainty what impact the codeine and Miss D’s decision to stop taking it, had on her deterioration and resulting hospital admission in December and we therefore need to take a balance of probabilities view. This is where we consider what is more likely than not to have been the reason behind the admission.

23. To reach a view we have taken into account the lack of any evidence of problems whilst Miss D was taking codeine, the lack of any previous mental health admissions for delirium or psychosis, a relevant medical study and Miss D’s medical records during her hospital admission which include her own explanations of what happened. Considering this evidence, we are satisfied that had she not decided to stop taking codeine suddenly, it is more likely than not, her deterioration admission and sectioning in December would have been avoided. Our psychiatry adviser shares this view.

24. Therefore, whilst we consider that Miss D should not have been prescribed codeine by the GP Practice, it was more likely than not that the sudden stopping of the medication, rather than the medication itself, caused Miss D’s deterioration and hospital admission.

1. We have seen failings in the prescribing of codeine, as Miss D should not have been prescribed this on account of her liver disease. We have not been able to link this failing to Miss D’s subsequent hospital admission. It is therefore likely that we will partly uphold this complaint.

2. We are recommending that the GP Practice acknowledge the failing we have identified and apologise to Miss D for the unnecessary worry this has caused her. We are also recommending that the GP Practice produce an action plan to prevent similar problems in the future.