A practice in the Surrey Heath area

4. Ms V complains about the care she received from the Practice between 25 January 2024 and 7 May 2024. She complains:

• she was incorrectly prescribed mirtazapine and sertraline anti-depressant medication when she sought treatment for insomnia • she was incorrectly prescribed citalopram anti-depressant medication when she sought treatment to withdraw from mirtazapine • she was incorrectly prescribed sertraline antidepressant medication when she sought treatment for serotonin syndrome • when all of these medications were prescribed to her, she was not informed about the potential side effects or withdrawal symptoms.

5. Ms V says the prescribed medication caused her distress and to suffer from agitation, anxiety, tremors, and blurred vision. She says the concurrent use of citalopram and mirtazapine, and prescribed sertraline have led to the development of serotonin syndrome and subsequent brain damage which impaired her cognitive ability and further caused muscle twitching, severe muscle atrophy and weakness and severe pain all over her body.

6. Ms V also says this caused her difficulty to manage day to day living including walking, doing housework and taking care of herself. She also lost her job and the financial security this provided.

7. To resolve her complaint, Ms V would like the Practice to acknowledge its failings and to apologise for their impact.

8. Ms V attended the Practice on 25 January 2024 after experiencing insomnia. A GP assessed her and noted that she had anxiety disorder.

9. To treat and manage her symptoms, the Practice prescribed Ms V various medications over a period of time. Her medication was reviewed on several occasions after she reported experiencing side effects, and the Practice monitored the effectiveness of the medication. Ms V was initially prescribed mirtazapine, following a review this was changed to citalopram, and she was later prescribed sertraline.

10. Mirtazapine can be used to manage anxiety disorders, including generalised anxiety disorder (GAD), as well as anxiety associated with depression. It is particularly helpful for patients who experience insomnia linked to anxiety. Citalopram is used in adults to treat depression and anxiety disorders. Sertraline is an antidepressant used to treat depression and can also be prescribed for mental health conditions such as social anxiety disorder.

11. GAD is a mental health condition characterised by excessive, uncontrollable worry about a wide range of situations. Symptoms may include, difficulty sleeping, feeling restless, and low mood or depression.

12. Between 25 January and 7 May, Ms V had 20 consultations at the Practice. During this period, she was assessed and reviewed by several GPs. She also attended the Emergency Department (ED) on several occasions. From 13 March, Ms V expressed concerns that she had developed serotonin syndrome, a serious condition caused by excessive serotonin activity in the brain and nervous system.

13. Ms V believes that the medication prescribed by the Practice caused her to develop serotonin syndrome.

14. From 20 May, Ms V travelled overseas and did not return to the Practice for any further treatment.

18. Ms V complains the Practice prescribed her medication incorrectly and that she was not adequately informed about the potential side effects or withdrawal symptoms. She says the medication led to the development of serotonin syndrome.

19. The Practice says citalopram and mirtazapine are a commonly used combination in general practice and that there was no evidential proof that Ms V had serotonin syndrome. The Practice reports that anxiety was discussed as an underlying cause, including treatment options and potential side effects, and that an agreement was reached to commence sertraline.

20. Our GP Adviser told us there is no diagnostic test for serotonin syndrome. It is not a test result or diagnosis based on a single scan or blood test, it is a clinical condition diagnosed from symptoms and medication history.

21. In January, GP (A) reviewed Ms V, who reported difficulties with sleep during a period of personal stress. The GP noted a problem of anxiety disorder, with a history of increasing anxiety and initial insomnia, for which she was using a natural sleeping aid.

22. To treat her anxiety, GP (A) prescribed Ms V with 15mg of mirtazapine, to be taken at night. The records indicate that she was given the usual starting advice, which would be expected to include advice on potential side effects, and the risks of medication.

23. BNF guideline mirtazapine states 15-30mg of mirtazapine once daily can be used for adults, then adjusted according to response to up to 45mg once daily.

24. Ms V says that she did not present with anxiety, that her primary concern was insomnia. She believed the mirtazapine medication had been prescribed to help with her sleep. She also says the Practice altered her medical records from a diagnosis of insomnia to GAD.

25. On 16 February, GP (A) reviewed Ms V, and the problem was noted as anxiety disorder. Ms V reported that she had initially felt some benefit from the mirtazapine but had subsequently experienced a less favourable week and remained concerned about her insomnia. The records show that the Practice sent information to Ms V about sleep science and she agreed to try and read it. Her mirtazapine medication was unchanged.

26. A few days later, on 21 February, Ms V spoke with a psychological wellbeing practitioner. During the assessment, standard measures of depression and anxiety were used to determine Ms V’s scores. For depression, she scored 18/27 indicating symptoms in the moderately severe range for low mood. For anxiety, she scored 16/21 indicating symptoms in the severe range. Due to these results, she was placed on a waiting list for one-to-one Cognitive Behavioural Therapy (CBT).

27. CBT is a talking therapy that helps people identify and change unhelpful thoughts and behaviours to improve how they feel.

28. By early March, Ms V reported side effects from mirtazapine. On 1 March, GP (B) assessed her. She reported feeling confused while taking the medication. GP (B) advised her to stop mirtazapine and to discuss alternative treatment options at her next appointment.

29. Three days later, on 4 March, GP (A) reviewed Ms V following concerns that mirtazapine was causing her confusion. GP (A) agreed to change her medication to 50mg of sertraline daily. Ms V was provided with information directing her to a website containing details about sertraline, including potential side effects and advice on stopping the medication.

30. BNF guideline sertraline states 50mg of sertraline once daily can be used for adults, with gradual increases according to response up to a maximum daily dose of 200mg.

31. Our GP Adviser told us that it can be difficult to clinically differentiate between physical symptoms of anxiety and medication side effects. When Ms V reported symptoms, her medication was either changed or discontinued. The medication changes were in line with guidance and all medications were prescribed at licensed doses in accordance with BNF guidelines.

32. Shortly afterwards, Ms V developed concerns about sertraline. On 13 March, GP (C) reviewed her. Ms V reported experiencing a feeling of “blood rush” and was concerned that she had developed serotonin syndrome while taking 30mg of mirtazapine and 50mg of sertraline. GP (C) felt this was unlikely and advised continuing with 15mg of mirtazapine and recommended Sleepio, a sleep therapy programme designed to help people improve insomnia.

33. Our GP Adviser told us Ms V did not comply with the advice given. On 1 March, she was advised to stop taking mirtazapine and on 4 March she was advised to take sertraline instead. Ms V took both medications for a period. When she was reviewed on 13 March she reported side effects from taking both medications.

34. Five days later, on 18 March, GP (D) reviewed Ms V following concerns of a panic attack whilst driving. GP (D) noted a problem of anxiety disorder and that she had been prescribed mirtazapine. GP (D) advised her to continue taking mirtazapine and explained that it could take several weeks for it to take effect.

35. On 27 March, GP (D) reviewed Ms V. She reported poor sleep, feeling groggy and more anxious. The GP recommended a reduction plan to wean off the mirtazapine over a two week period and then commence 10mg of citalopram daily.

36. The following day, GP (D) reviewed Ms V. She reported that she woken up feeling well and had taken citalopram. While a work, she became anxious and wondered whether this was due to the medications. GP (D) advised her to stick to the plan to wean off mirtazapine before introducing citalopram.

37. Ms V returned to the Practice and saw GP (A) on 2 April. She reported increased anxiety over the weekend and requested to stop her medication. In line with her request, the GP agreed to discontinue all medications and planned to reassess her in 10 days.

38. On 4 April, Ms V attended the ED with palpitations and chest tightness after recently stopping mirtazapine and citalopram medication, which she believed was due to serotonin syndrome. The ED carried out investigations and diagnosed anxiety disorder.

39. It is noted in the ED records her ECG showed normal rate and rhythm and her blood tests were normal. It was explained to Ms V that stopping her medications may have worsened her anxiety and could be the cause of her palpitations. There was no clinical concern that her presentation was evidence of serotonin syndrome. The ED recommended that Ms V continue with the GP’s plan.

40. On 9 April, GP (E) reviewed Ms V. GP (E) noted a problem of anxiety disorder with symptoms including sweating, palpitations and headache. Ms V was concerned she had developed serotonin syndrome after she started taking citalopram with mirtazapine. Ms V requested to restart sertraline as she felt she had tolerated this better. The records show that GP (E) discussed potential side effects and prescribed 50mg of sertraline daily.

41. NICE guidelines states a person with GAD can be referred to the Community Mental Health team (CMHT) for an assessment of needs and risks. The CMHT provides assessment, treatment, and support for people experiencing mental health difficulties in the community.

42. Over the following weeks, Ms V remained under review. On 23 April, GP (B) reviewed her. It is noted Ms V was very anxious. Later the same day, an urgent referral was made to the CMHT.

43. The CMHT triaged Ms V on 24 April. The team concluded that she appeared to have developed significant health anxiety, particularly focused on her heart and medication. A routine psychiatric review was recommended.

44. During the subsequent psychiatric review, Ms V believed that mirtazapine and citalopram taken concurrently had caused serotonin syndrome. The psychiatrist noted that she appeared tense and nervous and concluded that she had become highly focused on the belief that her medication had caused her harm.

45. On 25 April, GP (B), referred Ms V to neurology with a view to do a computed tomography (CT) head scan. A CT scan is a test that takes detailed pictures of the inside of a person’s body to diagnose conditions.

46. Ms V attended the Practice on 7 May. She informed GP (B) that she wanted to return overseas. The records show this was her last appointment.

47. On 20 May 2024, Ms V notified the Practice that she was seeing a psychiatrist overseas, who had prescribed mirtazapine and clonazepam. From documentation provided by Ms V, it is noted that whilst she was overseas she was admitted to a neurological hospital between 19 March 2025 and 1 April 2025. It appears that she was diagnosed with brain inflammation.

48. We recognise that receiving information of this nature would likely have been very distressing for Ms V, and we acknowledge the understandable concern this may have caused and may continue to cause for her.

49. It is recognised that following the treatment she received from the Practice in the UK, there was a period during which she travelled overseas and underwent further medical assessment and treatment, including the prescription and administration of medications. Given the passage of time and the intervening medical interventions received outside the UK, it is not possible to reliably attribute her diagnosis to the treatment provided by the Practice.

50. Our GP Adviser told us told us there is no evidence in Ms V’s medical records provided by the ED and the Practice to support a diagnosis of brain damage.

Conclusion

51. When we spoke to Ms V, she expressed concerns that her medical records were altered by the Practice and that the recorded diagnosis was changed from insomnia to GAD. Having reviewed the electronic records, which are digitally date and time stamped, we saw no evidence to suggest they had been altered.

52. We recognise Ms V does not accept the content or accuracy of the medical records and believes they do not reflect her experience. We explained to Ms V from the outset that our role is to review all available evidence and reach an independent decision based on the contemporaneous information recorded at the time of the events, alongside any other relevant material. The records consistently document a diagnosis of anxiety disorder.

53. We have not seen any indication of failings in the care and treatment provided by the Practice. The records support the view that Ms V was appropriately assessed, diagnosed with anxiety and that treatment options were discussed. She was prescribed appropriate medication in line with BNF guidelines.

54. We have carefully considered Ms V’s complaint. We can see that she was given appropriate advice when she was prescribed mirtazapine and sertraline. However, there is no evidence in the records to show that similar advice was provide when she was prescribed citalopram. When medications are dispensed, the packaging includes a patient information leaflet explaining how to take the medication including the potential side and withdrawal effects. For this reason, we do not consider the absence of documented advice to be a failing.

55. We recognise that it may be difficult for Ms V to accept this outcome, particularly given the strength of her feelings about this matter. We hope to assure her that we do not see anything to indicate service failure.

1. We have carefully considered Ms V’s complaint about the care and treatment provided to her by the Practice.

2. Having reviewed all the information available to us, we do not see any indications of failings in the complaints raised.

3. We thank Ms V for bringing these concerns to us. We hope that our view provides some reassurance to her. We explain our decision below.