A practice in the Croydon area

4. Mr T complains about the following aspects of care and treatment provided to his mother Mrs W between 4 January 2023 to 16 March 2023:

The Practice

• the Practice did not treat his mother’s intense stomach pain and malnourishment with any urgency.

5. Mr T believes his mother was in severe pain with her stomach leading to malnourishment and weight loss.

Croydon Health Services NHS Trust (the Trust) and South London and Maudsley NHS Trust (SLaM)

• the Trust discharged his mother prematurely on 16 March 2023, before she was medically stable

• SLaM rapidly increased his mother’s dosage of mirtazapine antidepressant medication over a three week period causing her to have hallucinations.

6. Mr T believes that when the Trust discharged his mother she was not medically stable. The day after her discharge on 17 March 2023, she jumped from a first floor window causing her to sustain injuries which required treatment. Mr T also believes that the rapid increase in mirtazapine caused his mother to have hallucinations and delusional behaviour.

7. To resolve his complaint, Mr T would like an acknowledgement of the failings and an apology for their impact. He would also like a financial remedy.

8. Mrs W had been experiencing abdominal pain for several months. She was referred to several specialists for investigations including a consultant gastroenterologist, a vascular consultant and an endovascular surgeon.

9. In January 2023, her case was discussed in a vascular multi-disciplinary team meeting. The team reviewed her previous computed tomography (CT) angiogram, which is a detailed scan that uses X-rays and contrast dye to produce images of how blood flows through the blood vessels. The scan showed that there were no significant vascular abnormalities.

10. On 27 January 2023, Mrs W spoke to her GP at the Practice about her ongoing abdominal pain and a treatment plan was put in place.

11. On 17 February, Mrs W attended the Trust’s Emergency Department (ED) and was admitted to a medical unit for further investigations.

12. Further investigations including a CT scan were performed but did not identify a specific caused for her abdominal pain.

13. The clinical team had previously considered superior mesenteric artery (SMA) syndrome as a possible explanation. This condition occurs when the artery compresses part of the small intestine which can lead to symptoms such as abdominal pain and difficulty eating. However, following further review of the findings, the clinical team concluded that SMA was unlikely to be the cause of her symptoms.

14. On 20 February, the Trust referred Mrs W to the Older Adults Psychiatric Liaison Team with suspected depression. She received mental health services with SLaM as part of an integrated care arrangement.

15. A psychiatric doctor assessed Mrs W and considered that her symptoms may have a functional or psychological origin, meaning that while no clear physical cause had been identified, the symptoms could be influenced by things such as stress, anxiety or depression.

16. Despite no previous history of mental health conditions, Mrs W presented with low mood, suicidal thoughts, insomnia and weight loss. On this basis, she was diagnosed with clinical depression.

17. To treat her depression, on 22 February, Mrs W was given 15mg of mirtazapine once daily. During her admission the dose was increased and at the time of her discharge she was prescribed 45mg once daily.

18. On 16 March, the medical team determined that Mrs W was stable and she was discharged from the Trust with follow-up support in the community.

19. On 17 March, Mrs W fell from a bedroom window and sustained severe injuries. She was admitted to the Trust for treatment and remained an inpatient until her discharge. Following her discharge, sadly, Mrs W suffered a second fall and died on 31 August 2023.

The Practice 23. Mr T says the Practice did not treat his mother’s intense stomach pain and malnourishment with any urgency.

24. The Practice says Mrs W’s symptoms were extensively investigated by the Practice and multiple hospital speciality teams and all reasonable steps were taken to manage her concerns and provide appropriate care.

25. On 4 January 2023, Mrs W contacted the Practice with lower abdominal and back pain. She reported that she had lost weight. The Practice records show that her symptoms were already under investigation by the gynaecology clinic and that during her appointment on 3 January, a magnetic resonance imaging (MRI) scan of her abdomen and pelvis had been recommended.

26. The following day she was seen by specialists in the gastroenterology clinic and also a vascular clinic to investigate the cause of her symptoms. The vascular team also discussed her symptoms in an muti-disciplinary team meeting and it was concluded that her blood vessels appeared normal. The specialists considered it unlikely that SMA syndrome was the cause of her symptoms.

27. A consultant gynaecologist saw Mrs W in clinic on 10 January. The results of her MRI scan were normal.

28. The Practice arranged a follow up telephone consultation with Mrs W on 12 January during which a doctor reviewed her ongoing symptoms and management options. This included consideration of a possible referral to a dietician and the pain team. A reminder was also given regarding her upcoming appointment with gynaecology and she was provided with advice about nutrition, fluid intake and medication.

29. On 18 January, a consultant obstetrician and gynaecologist at the Trust assessed Mrs W about her abdominal pain and associated urgency and pain opening her bowel. The doctor found that her pelvic examination was normal. A recent MRI scan showed nothing wrong in the pelvic area and a CT scan did not show any problems in her abdomen that could explain a gynaecological cause for her symptoms.

30. Our GP Adviser told us that Mrs W’s symptoms were complex and outside the expertise of the Practice. She had been referred to specialists, however no underlying cause for her symptoms had been identified.

31. GMC guideline states that in providing clinical care you must refer a patient to another suitably qualified practitioner when this serves their needs. Due to Mrs W’s concerns about her loss of appetite and weight loss, the Practice referred her to the dietetics team on 20 January.

32. She was further assessed by a doctor at the Practice on 24 January with concerns about her mouth and her inability to tolerate nutritional supplements due to burning pain. She was advised on treatment options and asked to arrange a further appointment to discuss pain management.

33. On 27 January, Mrs W contacted the Practice reporting severe pain and requested a mild morphine patch. She confirmed that her enquiry was not urgent and acknowledged it could take up to 2 working days to receive a response. A doctor contacted her the same day to discuss her symptoms during which the risks associated with morphine patches were explained. The doctor advised her to take famotidine to reduce stomach acid and Buscopan to relieve cramping and spasms.

34. Our GP Adviser told us the doctor did a focused assessment and explained why morphine was not prescribed, instead offering appropriate alternative treatments. The management of Mrs W’s symptoms was in line with BNF guidelines, using targeted treatments for the specific symptoms and avoiding higher-risk treatments unless clearly indicated.

35. The records show that on 1 February, the Practice prescribed Mrs W with butec transdermal patches, a strong opioid pain killer used to treat long term moderate to severe pain.

36. On 6 February, Mrs W visited her GP due to ongoing abdominal pain. She reported a reduced appetite and weight loss, as well as a blockage in her stomach that was preventing her ability to eat and drink. She also expressed concern that there may be an underlying issue with her kidneys.

37. GMC guidelines recommend a good standard of practice and care must be provided. This includes adequately assessing a patient’s condition including symptoms, carrying out a physical examination when necessary, and proposing effective treatment.

38. In accordance with GMC guidelines, a doctor examined Mrs W and noted her abdomen to be soft, with mild tenderness in her lower abdomen. On deeper palpation, she was comfortable and her bowel sounds were normal.

39. Mrs W reported that she had not taken any of the recently prescribed medications, as she was unable to tolerate them. The doctor advised her to continue with butec for a further four weeks to allow time for effect and to use paracetamol as needed for pain relief. She was also advised to start taking famotidine and Gaviscon after meals.

40. The doctor spoke to Mrs W at length about the investigations by the vascular team and what could be causing her symptoms and considered the possibility of chronic reflux and constipation. The doctor also advised dietary changes, including increasing her intake of more fortified foods. To provide reassurance, it was agreed that a blood test would be undertaken. The results, including a full blood count did not require any further action and her renal and liver function tests were within normal limits.

41. During the appointment, the psychological impact of her condition was discussed. The doctor advised Mrs W to book an appointment with IAPT (Improving Access to Psychological Therapies) for support with possible depression.

42. Our GP Adviser told us that the doctor thoroughly examined Mrs W. It would have been helpful if she had been weighed to enable a clearer picture of her current weight. The GP was honest that the cause of her abdominal pain was uncertain and whether it could potentially be chronic reflux. As Mrs W was concerned about her kidneys, the GP arranged a blood test, which did not require any further action.

43. Mrs W’s symptoms were ongoing and in such circumstances, a two week wait gastroenterology referral would have been indicated. However, she already had a follow-up appointment with gastroenterology scheduled within the two week timeframe.

44. The following day, Mrs W was triaged by the IAPT team. She reported experiencing symptoms of low mood and anxiety and the team agreed to refer her for a course of integrative counselling.

45. On 7 February, the Practice received a letter from a private dietician regarding Mrs W. The dietician understood that Mrs W had been diagnosed with SMA syndrome, however, this diagnosis had been considered unlikely by the vascular team. Mrs W was experiencing severe constipation and pain, weighed 39.2 kg, with a BMI of 14.4 and was described as very weak. The dietician recommended initiating a feeding tube to support weight gain and improve her strength.

46. On 10 February, a doctor at the Practice spoke to Mrs W about her symptoms. It was noted that these were getting worse and Mrs W felt that nothing was being done. She was taking laxido daily to help with her bowel movements and it was recommended to increase this and assess if she needed a proton-pump inhibitor, a medicine that reduces stomach acid.

47. Mrs W was not satisfied with the plan and wished to receive treatment as soon as possible. Although she already had an appointment with the gastroenterology team on 20 February the doctor advised her to attend the ED for more urgent assessment, which she declined.

48. Our GP Adviser told us that Mrs W was under the care of the gastroenterology team, as her symptoms and management were beyond the scope of management at the Practice. While the doctor could have requested an earlier review with gastroenterology, the existing appointment was due in 10 days and a more urgent assessment would not have been possible without her attendance at the ED.

49. The same day, a doctor at the Practice contacted the Trust’s dietetics team to request an urgent appointment for Mrs W due to concerns regarding her weight loss and oral intake in accordance with GMC guideline to refer a patient to another suitably qualified practitioner when this serves their needs.

50. Our GP Adviser told us that the Practice acknowledged Mrs W’s symptoms and made plans accordingly considering her complex presentation.

51. Mrs W did not raise any further concerns with the Practice about abdominal pain or malnourishment after 10 February.

52. Mrs W was already under specialist care to investigate possible causes of her ongoing abdominal pain. We think the Practice reviewed and managed her symptoms appropriately within the limits of general practice, given the complexity of her condition and involvement of hospital specialists.

53. It is noted that during an appointment on the 6 February, our GP Adviser told us that it would have been helpful for Mrs W to have been weighed. However, we also note that on 7 February she was weighed by a private dietician, and a letter containing this information was subsequently sent to the Practice who referred her to the Trust’s dietetics team.

54. A clear diagnosis could not be made in primary care alone due to the nature of her symptoms. The Practice therefore provided ongoing assessment, symptom management and ensured appropriate referrals and specialist input were in place in line with GMC guidelines. We will not uphold this part of the complaint.

The Trust and SLaM 55. Mr T complains SLaM rapidly increased his mother’s dosage of mirtazapine antidepressant medication over a three week period, which he believes caused her to experience hallucinations. He also says the Trust discharged his mother prematurely on 16 March 2023.

56. SLaM say Mrs W was diagnosed with depression and was prescribed increasingly higher doses of mirtazapine over a three-week period, which was ‘a relatively quick’ but not an inappropriate titration. The decision to discharge Mrs W was the decision of the medical team who concluded that there were no acute medical or surgical reasons for her to remain in hospital.

57. On 17 February, Mrs W attended the Trust’s ED and reported that she felt unwell and was unable to absorb nutrients or tolerate solid food. She was admitted to a medical ward for further investigation. While on the medical ward, Mrs W was referred to several specialist teams and underwent various tests to determine the cause of her symptoms.

58. A few days after her admission, Mrs W was referred to the psychiatric liaison team with suspected depression, anxiety and insomnia. She also had possible cognitive impairment meaning some problems with memory, thinking or concentration. She had no prior psychiatric history.

59. As part of the clerking process, a mental state examination (MSE) was carried out on 21 February. A MSE is a structured way of observing and describing a person’s current mental functioning, giving clinicians insight of how someone is thinking, feeling and behaving at that moment in time.

60. During the MSE, the team noted that Mrs W’s abdominal issues began around two years ago and she felt her mood had got progressively worse. She described issues of pain, cramping and nausea which were impacting her mental health. She felt that insomnia was impacting her mood, as she was only getting around one to two hours sleep per night. She described her mood as ‘low’ and acknowledged suicidal thoughts but denied any intent or previous attempts. There was no evidence that Mrs W’s thinking was impaired or that she was experiencing things that were not real. Her risk was assessed as low and she was diagnosed with clinical symptoms of depression.

61. The same day, the clinical team held a multi-disciplinary meeting (MDT) to discuss Mrs W’s diagnosis. An MDT is a group of different healthcare professionals who work together to review and plan a patient’s care. As Mrs W had reported low mood and poor sleep, the team recommended starting her on mirtazapine, an antidepressant medication.

62. NICE guidelines recommend a combined approach to treating depression with pharmacological treatments such as starting antidepressant medication and psychological therapy. Psychological therapies are usually provided on an outpatient basis for patients with depression.

63. On 22 February, Mrs W was started on a low dose of 15mg of mirtazapine. BNF guidelines state ‘Initial adult dose in adults is 15-30mg once daily, typically administered for 2-4 weeks. The dose may be increased with a maximum daily dose of up to 45mg once daily.

64. SPC guidelines state ‘Psychiatric disorders such as nightmares, mania, hallucinations and restlessness are uncommon and they may occur in more than 1 in 1,000 people but fewer than 1 in 100 people who take the medication.’ This means, that fewer than 10 people in every 1000 may experience these effects.

65. Our Consultant Adviser told us older adults are considered at higher risk of adverse effects partly due to reduced renal clearance, mirtazapine is approximately 75% renally excreted. This means Mrs W’s kidneys were not able to clear the drug from her system effectively. In addition, comorbid conditions and a susceptibility to effects such as confusion or hallucinations, may further increase the likelihood of adverse reactions.

66. The psychiatry team regularly reviewed Mrs W, a doctor assessed her on 1 March. During the assessment, she was asked how she felt about being discharged home. Mrs W stated that she would prefer to feel better before returning home and the doctor noted a sense of optimism in her response.

67. As her symptoms persisted, she reported fluctuations in her mood, but no specific pattern and poor sleep. Her mirtazapine dosage was increased to 30mg. Our Consultant Adviser told us, there is no widely accepted knowledge that increasing mirtazapine quickly makes hallucinations more likely. When they do occur, it seems to be an unpredictable reaction in certain people, rather than something caused by how the body processes the drug.

68. During a further review by the psychiatry team on 7 March, Mrs W continued to report low mood associated with pain and poor sleep. Mrs W spoke about challenging times in her life and when she was asked to pinpoint in her body where she felt her emotional pain lived, she pointed to her stomach. There was no evidence that Mrs W’s thinking was impaired or that she was experiencing things that were not real.

69. The psychiatry team concluded that Mrs W was unable to make the connection between the physical symptoms and her mental state and recommended a further increase to her mirtazapine dosage from 30mg to 45mg once a night.

70. Mrs W’s son raised concerns with the clinical team on 7 March about his mother’s mental state. Specifically, he reported his mother was having paranoid thoughts about the ceiling cameras and she had told him she could see sugar in her nerves and veins. Her son believed this was a rare side effect of the mirtazapine and asked the team to review her medication.

71. We have seen that the clinical team spoke to the nurse caring for Mrs W. The nurse confirmed that Mrs W had not conveyed anything to support that she was experiencing hallucinations. However, we do not doubt that this was Mr T’s genuine perception.

72. SLaM says the psychiatric liaison team felt that her reported symptoms were more likely anxiety related than psychosis or related to mirtazapine. Our Consultant Adviser told us, it is not possible to exclude mirtazapine as a contributing factor to Mrs W’s hallucinations. However, based on clinical assessment, it is more likely that these symptoms reflected an underlying psychiatric condition which may have been exacerbated during mirtazapine treatment.

73. On 10 March, a doctor from the liaison psychiatry team assessed Mrs W in the presence of her family. The doctor explained the role of mirtazapine was to alleviate anxiety and depression and it would take 2-4 weeks to take effect.

74. Mrs W’s son acknowledged that his mother had been eating and sleeping better since she had started the medication. The doctor explained that it was unlikely that mirtazapine was causing her symptoms, rather her emotions gradually re-surfacing and planned to discuss increasing her dose of mirtazapine to 45mg at her next review.

75. Our Consultant Adviser told us, the increase in Mrs W’s dosage was quite fast but there were indications it was helping with sleep and weight gain so this would be reasonable and in line with BNF guidance.

76. During this assessment, Mrs W’s son expressed concerns regarding her discharge. He was reassured that arrangements for her community care would be made closer to the time of discharge, based on her needs. The plan was for her to continue receive ongoing psychiatric input.

77. On 15 March, the psychiatric team spoke with Mrs W’s son regarding her follow-up support in the community after discharge. It was explained that she would be referred to the community mental health team (CMHT), who would monitor her progress and determine her suitability for referral to psychological therapies when her mental state was more stable.

78. On 15 March, the nursing team increased Mrs W’s dose of mirtazapine to 45mg once a night and she was discharged the following day with follow-up support in the community. Our Consultant Adviser told us mirtazapine doses are commonly adjusted at home, so increasing her dose to 45mg would not have prevented her from being discharged.

79. If a patient is due to be discharged from a medical ward and there are significant concerns about their mental state and risk, consideration may be given to referral to a Crisis Resolution and Home Treatment (CRHT) team.

80. NICE guideline states that CRHT can be considered for people who are at significant risk of suicide, self-harm, harm to others or self-neglect, as an alternative to inpatient admission. Inpatient psychiatric treatment can be considered for people with more severe depression who cannot be adequately supported by a CRHT team.

81. SLaM say from the assessments carried out and Mrs W’s mental state at the time, she did not appear to have met the threshold for needing psychiatric admission.

82. Our Consultant Adviser told us that Mrs W’s presentation was consistent with a diagnosis of severe depressive episode without confirmed psychotic symptoms. If psychotic symptoms had been established, inpatient admission may have been considered depending on her insight and capacity to understand her mental health.

83. While in hospital, the psychiatric team regularly assessed Mrs W. During an assessment on 7 March, a doctor noted ‘there was no evidence of thought disorder or perceptual disturbance during the review’. Psychotherapy, a term used for talking-based treatments, was offered, however this was declined.

84. Our Consultant Adviser told us that Mrs W had not described any significant risks, such as suicidal plans or behaviour. The fact that there is no documented consideration of psychiatric admission indicates Mrs W was not approaching the threshold for admission. In this case, a plan for psychiatric management via the Community Mental Health Team (CMHT) was appropriate.

85. The CMHT can provide ongoing assessment, treatment planning and referral for psychological therapies as appropriate. A follow-up plan for psychiatric management was made for Mrs W, this included the following:

• referral to Older People’s CMHT for community follow-up upon discharge from hospital • family informed that the CMHT would contact Mrs W mother upon discharge and arrange an initial visit • CMHT will decide suitability for referral for psychological therapies when mental state is more stable • CMHT to carry out cognitive tests when Mrs W is at baseline after anxiety resolves.

86. With a plan in place, Mrs W was discharged on 16 March.

87. We think that the Trust’s decision to discharge Mrs W was appropriate. At the time of discharge, she was medically stable, had been appropriately assessed by the psychiatric team, and did not present with risks that would require inpatient psychiatric care. A clear and appropriate plan was in place for ongoing support in the community in line with NICE guidance. We will not uphold this part of the complaint.

88. We also think that SLaM increased Mrs W’s mirtazapine dosage appropriately. Although the titration occurred over a relatively short period, it remained within accepted prescribing guidance. While hallucinations are a recognised but uncommon side effect, there is no established evidence that more rapid dose escalation increases this risk. On balance, the available evidence shows that the prescribing and management of mirtazapine was in line with BNF guidelines. We will not uphold this part of the complaint.

89. We are grateful to Mr T for bringing his complaint for our consideration. We understand this has been a very distressing and upsetting time. We hope to assure him, that we do not find any evidence of service failure. This concludes our report.

1. Mr T complains about the care and treatment provided to his mother, Mrs W, between 4 January 2023 and 16 March 2023 by the three organisations. Mrs W very sadly died on 31 August 2023. We extend our condolences to Mr T and his family and recognise these events continue to cause them significant upset and distress.

2. We do not see any evidence of any failings in the care provided to Mrs W by any of the organisations we have investigated. We have decided to not uphold this complaint.

3. We recognise the considerable distress Mr T has experienced, and hope this report provides him assurance that his mother’s care aligned with the expected standards.