An independent provider in the Cornwall area

4.Miss O complains about the actions of an independent mental health care provider (the Organisation) between October 2023 and January 2024. Specifically, she says:

•her titration prescriber did not communicate with her properly or provide adequate support •the Organisation discharged her from its service.

5.Miss O tells us the events have caused her anxiety, depression, mood swings and a loss of trust in the Organisation. She added she has been left without support or medication since she was discharged from the service.

6.Miss O wants the Organisation to apologise to her and pay her compensation.

7.Miss O had been under the care of the Organisation prior to the events leading to the complaint.

8.Due to previous difficulties regarding her titration, the organisation started a new titration period in October 2023. Miss O tells us there was lack of support and communication from her titration nurse and there were delays with her medications being sent out.

9.In January 2024, Miss O wrote to the Organisation to request a new titration nurse. A few days later, the Organisation responded and explained she had been discharged from the service. Miss O complained to the Organisation a few days after being discharged.

13.Miss O says during her titration period from October 2023, her titration prescriber did not provide adequate support or communicate with her properly. Miss O says that during this titration period, she consistently encountered difficulties and feels there was a lack of engagement from her prescriber to check on her progress or check the required forms for her titration were being filled out.

14.Miss O says these events caused her mental health to worsen and says she has lost trust in the Organisation. We are sorry to learn how these events have impacted Miss O and appreciate the importance of her complaint.

15.In its complaint response, the Organisation confirmed it had reviewed the case with the prescriber who felt they had offered Miss O one off support, but confusion had occurred in which Miss O thought she would have regular follow ups with her prescriber, which is not part of the Organisation’s procedure.

16.The relevant NICE guidance says:

‘Ensure that children, young people and adults receiving treatment for ADHD have review and follow‑up according to the severity of their condition, regardless of whether or not they are taking medication.’

17.Our adviser explained it would be good practice for a clinician to maintain contact with a patient during a titration period. However, we acknowledge organisations may have their own systems / policies in place regarding how they communicate with a patient.

18.The primary reason for the Organisation discharging Miss O (we will cover the discharge in more detail further on in this statement) was lack of engagement and absence of medication monitoring forms from her.

19.We understand that the Organisation monitors the success of medication in its patients via monitoring forms. When a patient has started a titration period, the Organisation sends a medication monitoring form to the patient every two weeks to judge the success of the prescription. The monitoring forms require a patient to record their blood pressure, pulse, weight and side effects/improvements from the medication. Miss O has confirmed she was aware that during the titration period, the monitoring forms were required.

20.The Organisation said in its complaint response that when Miss O started her titration period in October, a letter was uploaded for Miss O which clearly stated that if she failed to provide updates via medication monitoring forms three times, it would result in her being discharged from the service.

21.Steps one, four and five of the Organisation’s SOP on disengagement say:

‘The patient misses an ADHD monitoring update form. This will result in a 1st missed form (“strike”) on their titration record and will be recorded in the portal waiting list. The 1st “strike” will appear in amber to alert the prescriber.’

‘Following any of the possible 3 “strikes”, whilst in titration, the prescriber should review the patient’s experience and engagement. They can make a clinical decision to remove any of the strikes at the time they arise.’

22.Miss O’s first prescription in the titration period was issued in mid-October. In late October, the Organisation recorded that the medication was back with the pharmacy as the delivery was unsuccessful. It appears the Organisation was aware Miss O had not received any medication in October. Miss O confirmed to the Organisation she received her medication in early November.

23.Throughout November, there is no evidence of any contact from the Organisation to check whether Miss O had continued to receive her medication or to check why there had not been any medication monitoring forms from her. Our adviser said that the Organisation should have contacted Miss O and reviewed her experience and engagement. We consider there to be failings here due to step five of the Organisation’s SOP specifically stating the prescriber should review the patient’s experience and engagement in the absence of any medication monitoring forms.

24.In early December, the prescriber contacted Miss O, said her titration period was over and asked if everything was ok. Miss O responded to the prescriber querying how the titration period was over given she did not receive her medication until early November. The prescriber then responded to Miss O asking her to complete the medication monitoring forms.

25.Throughout the rest of December, there is no evidence to suggest there was any further contact from the prescriber to check on Miss O’s engagement including why there had not been any medication monitoring forms. We consider there should have been some contact to review the situation, in line with the Organisation’s SOP. The Organisation then discharged Miss O in early January after she requested a new titration nurse, giving the rationale she had not engaged with the service and not provided any medication monitoring forms.

26.Since Miss O’s first prescription of the titration period was issued in October, there were only two attempts of contact from the prescriber. Our adviser gave their view that those contacts from the prescriber did not adequately explore Miss O’s progress, any difficulties she was having, her experience, or her overall engagement.

27.The Organisation’s SOP suggests it expects the prescriber to monitor the situation closely in the absence of medication monitoring forms. Step five of the Organisation’s SOP states if there are three missed monitoring forms, the prescriber should review the patient’s experience and engagement. There is no evidence in the records to show this was done. We consider there to be failings in that the Organisation has not followed its own operating procedures in relation to reviewing Miss O’s engagement and any reasons for the missed medication forms, especially as this was the reason given for her subsequent discharge from the service.

28.Miss O explained there were multiple reasons for her not providing the medication monitoring forms. She said that on occasion she was locked out of the Organisation’s online portal and was unable to log in to complete the forms. Miss O added that during the titration period, there were large periods where she did not receive any medication meaning she couldn’t provide a monitoring form.

29.Miss O acknowledged that she did sometimes forget to do the forms and said that was because of her ADHD symptoms. She explained her previous prescriber would often remind her to complete the forms. We understand there is no expectation for the prescriber to remind Miss O to complete the forms. However, we do consider that on balance, Miss O’s engagement (including providing the monitoring forms) may have improved if the prescriber reviewed this with her as per the Organisations SOP.

30.Miss O says the events caused her mental health to worsen during her titration period. We can understand how the lack of communication from the prescriber during the titration period would cause Miss O distress and anxiety.

31.We consider the lack of communication to have increased Miss O’s distress during her titration period. Miss O told us these events caused a significant loss of trust in the Organisation which we also consider to be an injustice to her. The lack of communication evidently left Miss O feeling unsupported and unsure about her treatment progress given she requested a new prescriber.

32.In summary, we have found the Organisation did not follow its own operating procedures, specifically in communicating with and monitoring Miss O’s progress during her titration period.

Discharge

33.Miss O is unhappy that shortly after she asked for a different prescriber, she was discharged from the service. She said this caused her additional distress and left her without support or medication. We are very sorry to hear this and acknowledge this has been a difficult period for Miss O, especially as she has not been getting her medication from elsewhere.

34.The Organisation confirmed in its complaint response that since Miss O received her medication in November 2023, there had been no medication monitoring forms from her, and as per its letter (outlined in para 22), that resulted in discharge, which it said was correct.

35.The Organisation said its titration lead reviewed Miss O’s case and maintained the decision to discharge her. It explained it needed regular contact from a patient, and it would be unsafe to continue titration for patients who do not engage in the titration process.

36.As we have explained, we consider there to be failings in that the prescriber did not follow the Organisation’s SOP in respect of contacting Miss O to review her engagement and identify any difficulties she may have been having after she had not provided her medication monitoring forms.

37.Our adviser said there are things the Organisation should have addressed before it got to the point of discharging Miss O. Our adviser gave their view that Miss O may not have fulfilled the criteria for discharge.

38.Our adviser explained that the Organisation presumed Miss O was not engaging during her titration period which commenced in October 2023, without exploring her experience or engagement, which is something that should happen in line with the SOP.

39.There is a note in the records from December 2023 in which Miss O told her prescriber she had not been able to log into the online portal. Miss O confirmed this was one of the reasons why she had not been providing the medication monitoring forms. There is no evidence to suggest this was explored with her as an explanation for the absence of the monitoring forms. The Organisation’s SOP specifically states strikes for a missed update can be removed for reasons such as IT issues.

40.We consider that if the prescriber reviewed Miss O’s engagement and explored any difficulties she was having (following a missed medication form), this may have led to improvement in engagement.

41.We cannot definitively know what would have happened if the prescriber had reviewed Miss O’s engagement after each missed medication monitoring form. She may still have not provided her weekly monitoring forms. However, we consider that Miss O was denied the opportunity to improve her engagement in the absence of regular reviews by the prescriber.

42.Miss O says the discharge meant she was left without support or medication. We consider the discharge may have been avoided if the prescriber followed the Organisation’s SOP on engagement during the titration process.

43.Our principles for remedy say that where poor service has led to injustice, organisations should try to offer a remedy that returns the complainant to the position they would have been in otherwise.

44.In a further written response from the Organisation dated July 2024, it said that as a result of the confusion and Miss O’s complaint, it could offer Miss O re-admission to the service for a fresh 12-week titration period. We do consider this offer of re-admission to be appropriate and in line with our principles for remedy. Miss O confirmed she declined this offer as she had lost trust in the Organisation.

45.As Miss O was given the opportunity for a new titration period in July 2024, we cannot attribute any fault to the Organisation for Miss O being left without any support or medication after that point. However, we do consider the discharge in January 2024 to have been potentially avoidable meaning we consider the period from January – July 2024 to be an injustice to her as she was not receiving any support or medications.

46.In summary, we consider that Miss O was denied the opportunity to improve her engagement as the prescriber did not follow the Organisation SOP to review her engagement. We consider this may have led to Miss O’s potentially unfair discharge in January 2024 and subsequently meant she was without support or medication for the period until she was offered a new titration period.

1.We are sorry to learn of the events which led Miss O to make a complaint. We acknowledge the difficult experience she had during her titration period with the Organisation, and we understand the importance of her complaint.

2.We have found the Organisation did not follow its own standard operating procedures during Miss O’s titration period. We have found this may have led to the unfair discharge of Miss O from the service. We consider these events caused Miss O distress and anxiety and resulted in a period without appropriate support or medication.

3.Our final decision is to partly uphold this complaint, and we make recommendations at the end of this report

47.We make recommendations in line with our Principles for Remedy which say public organisations should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public organisation puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public organisation should compensate them appropriately.

48.Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

What we found

49.Through investigating this complaint, we found the Organisation did not act in line with its own SOP relating to engagement during a patient’s titration process. We have found that this caused Miss O to suffer distress, anxiety and potentially led to an unfair discharge meaning Miss O was left without support or medication until the Organisation offered her a new titration period (a period of approximately six months).

What the organisation should do

50.In line with our principles, we recommend that that within one month of the date this report, the Organisation writes to Miss O to apologise for the failings we have identified.

51.To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. We consider the injustice Miss O has experienced is level three on our scale.

52.We recommend the Organisation pays Miss O £600 within one month of the date of this report.

53.Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.

54.We consider the Organisation already has appropriate procedures in place to avoid the same things from happening in the future, and therefore we are not looking for the Organisation to make any changes/improvements to this. We recommend that within three months of the date of this report, the Organisation develops a SMART action plan to address the failings we have identified in paragraph 49. The SMART action plan should address how the Organisation will take steps to ensure it follows its standard operating procedures moving forward.