An independent provider in the City of Derby area

NHS 111 5. Mr O complains, on 23 May 2025, NHS 111 inappropriately referred him to a pharmacy for advice on switching from lurasidone (antipsychotic medication used primarily to treat schizophrenia) to cariprazine (an antipsychotic medication to treat mental health conditions) and did not provide safety net advice on the risk of his psychiatric medication.

Out-of-Hours GP 6. Mr O also complains about the out-of-hours GP on the same date. He says the out-of-hours GP had not heard of lurasidone and failed to advise on his medication, provide safety net advice, and refused his request for a second opinion.

7. Mr O was left very upset and distressed that his mental health had been put at risk and that he could not get the care he needed at a critical time. This has caused him to lose faith and trust in the NHS. He says the actions of NHS 111 and out-of-hours GP caused him emotional and psychological distress.

8. He would like an apology, acknowledgement of failings, service improvements to include mandatory training and process change around psychiatric medication. He would also like financial compensation.

9. Mr O has a diagnosis of schizophrenia (a type of psychosis that causes people to perceive or interpret things differently from those around them) and schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms).

10. On 20 May 2025, Mr O’s psychiatrist prescribed cariprazine to replace lurasidone. He says he was not given a titration plan or safety guidance. Mr O has not made a complaint to the Trust on this issue.

11. On 23 May 2025 he contacted NHS 111 for urgent advice on switching his psychiatric medications. Mr O says he was unsupervised during this transition and had concerns. NHS 111 offered to refer him to a pharmacist, which he says was inappropriate.

12. A second call to NHS 111 led to out-of-hours GP who he says was unfamiliar with lurasidone and declined to assist, advising Mr O to contact his psychiatrist or book a routine GP appointment.

NHS 111

17. NHS England guidance explains that NHS 111 provides advice and directs patients to the most appropriate service when urgent care is needed. This can include a referral to A&E, urgent treatment centre, emergency dental services, pharmacy, a GP, or arranging an ambulance in serious cases.

18. On 23 May 2025 Mr O called NHS 111 for urgent advice after being instructed by his psychiatrist to switch from lurasidone to cariprazine without a titration plan.

19. We listened to the call recording from 6.03pm. Mr O said he was seeking advice on how to manage the medication change, as he was not given a cross-titration plan. The NHS 111 adviser asked Mr O if he had any symptoms due to the medication change. Mr O reported distress and difficulty concentrating but did not attribute these symptoms to the medication change.

20. The NHS 111 adviser explained that a pharmacy could provide advice on medication transitions and offered to refer Mr O to a local pharmacy. Mr O declined this option, as he did not believe it would be helpful.

21. The adviser then offered that he speak to his own GP first, and to call NHS 111 back if he could not get hold of his GP, and it will make a referral to the out-of-hours GP. Mr O made a second call to NHS 111 at 7.35pm and it made a referral to an out-of-hours GP.

22. NHS 111 advisers are expected to assess a caller’s symptoms and direct them to the most appropriate service based on clinical needs. They are not expected to provide detailed medication management advice but should ensure callers are signposted to an appropriate service, such as GP or pharmacist, which can address medication queries.

23. The evidence shows the adviser appropriately assessed whether Mr O was experiencing symptoms requiring urgent escalation. While he reported distress and difficulty concentrating, he did not attribute these symptoms to the medication change, and there is no evidence he described severe or life-threatening symptoms.

24. The adviser appropriately identified that Mr O’s query related to medication management and offered to signpost him to a pharmacy. When Mr O declined, the adviser took reasonable steps to refer him to his GP.

25. We therefore have seen no indication of a failing in relation to this complaint point.

Out-of-Hours GP

26. Mr O complains that the out-of-hours GP did not know the medication lurasidone, failed to give him advice about his medication, did not provide safety net advice and refused his request for a second opinion.

27. The Good Medical Practice guidance domain one, requires doctors to provide suitable advice, investigation or treatment where necessary. It also states that doctors should only propose, provide or prescribe drugs or treatment when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet the patient’s needs.

28. The BMA guidance explains that GPs should only prescribe for a patient’s urgent medical problem. In practice, this may include patients who have lost their prescription, require maintenance methadone (drug addiction like heroin or opium), have travelled without their regular medication, or encountered problems obtaining prescribed medication at the pharmacy. The GP must make a clinical judgement on whether to prescribe in these situations.

29. We sought clinical advice from our adviser. Our adviser confirmed that referring Mr O to the out-of-hours for medication advice when his own GP surgery closed was inappropriate. There was no evidence of any acute medical health deterioration. Our adviser also confirmed that Mr O’s medication is specialist medication that GPs do not normally initiate. There was no impact to Mr O because on listening to the call, he seemed to agree with the GP’s advice.

30. The out-of-hours GP acted within their competence and responsibilities under the GMC guidelines. Mr O needed specialist advice which he should have sought from his own mental health team. The responsible clinician to discuss his medication was his psychiatrist, not a GP.

31. Our adviser reviewed the call recorded and noted that the GP gave appropriate advice, Mr O should continue his current medication until he could seek further advice, which Mr O seemed to agree with. Our adviser also explained that a second opinion would need to come from a psychiatry team and an out-of-hours GP cannot arrange that. Mr O seemed satisfied with the advice during the call and felt it was okay to wait for his next psychiatry appointment on 6 of June.

32. We therefore have seen no indication of a failing in relation to this complaint point.

Conclusion

33. We recognise that managing an unplanned change in psychiatric medication without a clear plan is distressing, and we are sorry that Mr O felt poorly supported when he reached out for help. Having reviewed both the NHS 111 calls and the out-of-hours GP’s response, each organisation acted appropriately within their respective roles. NHS 111 correctly offered to signpost him to a pharmacy. We understand NHS 111 did not need to refer Mr O to the out-of-hours GP, but we can see they gave safe, responsible advice within their own competence.

1. We have carefully considered Mr O’s complaint about NHS 111 and out-of-hours GP. We are sorry to learn of Mr O’s distressing experience.

2. The NHS 111 adviser acted in line with their role by assessing Mr O’s symptoms and directing him to appropriate services. They offered reasonable options including pharmacy and GP referral and respected Mr O’s decision to decline pharmacy referral. We have seen no indication NHS 111 did anything wrong in the service it provided Mr O.

3. The out-of-hours GP gave safe, responsible advice within the remits of their knowledge and competency, in line with GMC guidance, and therefore we have seen no indication of a failing.

4. We have explained the reason for our decision.