A practice in the North Tyneside area

3. Mr P complains the Practice did not restart his prescription for aripiprazole after his discharge from a mental health section.

4. He says the Practice left him without his antipsychotic medication for almost six weeks. This caused periods of psychosis, led him to self-harm and he lost his job.

5. He would like the Practice to offer him a financial remedy in recognition of the impact of its mistakes on his life.

Background

6. On 17 September 2023, Mr P was sectioned under the Mental Health Act and admitted to a local hospital following an overdose of prescription medication. After his discharge he contacted the Practice as he felt his mental health was declining. On 10 December, the Practice discovered it had not restarted his prescription of aripiprazole following his discharge.

10. On 14 September 2024, Mr P was admitted to hospital following an overdose of prescription medication. On 16 September, the Practice received a discharge summary from the hospital indicating it had stopped Mr P’s prescription of aripiprazole and the Practice actioned this.

11. On 17 September, Mr P was sectioned under the Mental Health Act and admitted for inpatient psychiatric care. During the admission, the mental health team restarted his prescription of aripiprazole at 7.5mg daily. Mr P was discharged on 19 September, with a seven day supply of medication, with instructions for the regular pharmacy to continue the supply from 26 September.

12. The mental health discharge summary confirmed the mental health team had restarted Mr P on aripiprazole. The Practice received this on 3 October. It did not add this to Mr P’s medication prescription. Mr P’s pharmacy was able to dispense aripiprazole using existing repeat prescriptions and it maintained his supply of the medication until 30 October.

13. Over the following weeks Mr P contacted the Practice concerned about his mental health. On 10 December, Mr P’s GP reviewed his medical records and noted it had not included the aripiprazole in his prescription. The Practice prescribed the medication, and it was available on 12 December.

14. In its complaint response, the Practice acknowledged it had made a mistake in how it processed the 19 September discharge summary. It acknowledged that due to this, it did not restart Mr P’s aripiprazole until December.

15. The General Medical Council’s (GMC) ‘Good medical practice’ says medical professionals should consider and act appropriately on information and advice from other healthcare professionals. It says this is especially the case if there are changes to a patient’s medicines.

16. It is clear from the Practice’s response that it did not act in line with this guidance when it did not prescribe Mr P’s antipsychotic medication from 19 September. The Practice has told us this was due to a systems workflow failure, rather than a failure to clinically consider the psychiatrist’s recommendations. But the GMC guidance still applies as the Practice should ensure its systems support its ability to act in line with relevant guidance.

17. Mr P says he did not notice the Practice had not prescribed the aripiprazole because he was taking a large amount of medication daily. His records show he was taking around 15 medications and supplements a day, so we can understand why he did not realise one was missing. When we weigh up the evidence, we have found a failing in the Practice’s actions. We have looked at the impact of this.

18. Mr P says during the time he was without medication, he suffered periods of psychosis, self harm and trauma. He said this continued after the Practice had realised its mistake and restarted the medication as it had to get back into his system. The Practice did not comment on the effect this had on Mr P’s mental health.

19. The Practice told us it prescribed Mr P aripiprazole for emotionally unstable personality disorder (EUPD). There are no NICE recommendations about the effects of long term treatment of aripiprazole for EUPD symptoms.

20. When Mr P was admitted to hospital on 16 September, he was experiencing auditory and visual hallucinations and had episodes of self harm. The hospital restarted his prescription of aripiprazole. This suggests the hospital believed the medication was of some therapeutic benefit for Mr P, whether that was for mood or hallucinations.

21. Mr P had enough aripiprazole to take until 30 October. It was next available from the Practice on 12 December. So Mr P was without it for almost six weeks.

22. Based on the information set out in The National Library of Medicine guidance about how aripiprazole breaks down, it takes around two weeks for the drug to leave the system. Our adviser explained that nearly six weeks is long enough that the therapeutic exposure of the drug would have dissipated for most people. This would therefore effectively be a treatment discontinuation.

23. Our adviser explained that the discontinuation of aripiprazole can lead to deterioration in sleep, agitation/anxiety, mood instability, paranoia and hallucinations. These symptoms can increase risks of self-harm, conflict with others, poor judgement, and so on.

24. Mr P’s medical records are extensive, and we can see he has struggled with his mental health, historically and after the time of the events in his complaint. When Mr P was under mental health section, he had auditory and visual hallucinations and episodes of self harm. We can also see Mr P had very worrying external factors in his life at the time; his girlfriend had a brain tumour and he had a back injury.

25. Our adviser explained the 7.5mg dose of aripiprazole Mr P had been taking is a relatively low dose for an adult of his age, though still within a therapeutic dose range. At the time Mr P was without aripiprazole, the mental health team had also prescribed diazepam. We can see he was taking other medications for his mental health.

26. When we weigh up all the evidence, we cannot say, on the balance of probabilities, that Mr P would not have self harmed or experienced psychosis if the Practice had continued prescribing his aripiprazole.

27. Mr P said that on 12 December, his employer terminated his contract during his probation period. He explained that he was hearing voices and having hallucinations while he was at work. Mr P worked in social care and explained his colleagues were caring for him while he was in a mental health crisis. He explained this was not appropriate and he could not return to his job. When we look at this and the external factors Mr P had in his life at time, we also do not think we can say, on the balance of probabilities, that he would not have lost his job if he had continued to take the medication.

28. But we acknowledge not having an important medication for nearly six weeks will have had some impact on Mr P. The GP records show he was very unwell and was asking for help in late November and early December. During this time, he thought the Pharmacy had set up an app on his phone to invite strangers to his home. He told the Practice he thought he was in psychosis, had harmed himself and might end his own life. Our adviser explained that suicidal ideation and self-harm with insight suggests worsening crisis in the context of EUPD.

29. Mr P had reported finding aripiprazole helpful to manage his symptoms and had reported worsening hallucination like experiences without it. While we cannot say there was a definitive link between the discontinuation of aripiprazole and Mr P’s worsening mental state, we cannot disregard his lived experience.

30. Our adviser said antipsychotics can help with mood and may help reduce distress, leading to an improvement in unusual experiences like hallucinations. So the Practice’s mistake meant Mr P did not have the best chance of experiencing the stabilising/anti-distress benefit the medication was intended for, increasing his vulnerability to crisis symptoms.

31. Mr P’s mental health was declining for weeks, he felt very unwell and he then discovered the Practice had not been prescribing his aripiprazole. We cannot say Mr P would not have had the symptoms he described, but he is left not knowing if he could have had a better experience. It made an already very emotionally difficult time for him even worse.

1. We partly uphold the complaint about the Practice. We have found the Practice did not prescribe Mr P’s antipsychotic medication for almost six weeks when he should have had it throughout that time. We have not found it was the reason for his periods of psychosis, self-harm and the loss of his job. But we think it denied him the best chance of experiencing the intended effects of the medication. He will never know if things could have been better for him and we recognise this has made the experience worse for him.

2. We recommend the Practice pays Mr P a financial remedy to recognise the effect its mistake had on him.

32. The NHS Complaints Standards say organisations should identify suitable ways put things right for people. Mr P wants the Practice to offer him a financial remedy to recognise the impact its mistake had on him.

33. The Practice restarted Mr P’s medication, and we are pleased it did this. It did a very detailed significant event analysis and it discussed the mistake in a Practice meeting. It is confident this was an isolated system error, but accepts full responsibility for it. We think it took the complaint seriously and took learning from this. It also apologised for its mistake. These actions are in line with NHS Complaint Standards. But we think there is more the Practice should do to put things right for Mr P.

34. Our Principles of Good Administration set out what organisations should do when it cannot put the person back in the position they would have been if nothing had gone wrong. It explains the remedy should reflect the impact the person has suffered.

35. Although we cannot say Mr P could have avoided his experience while he was without the medication, he still suffered as a result of the mistake. He did not have the best opportunity to experience the intended effects of the medication so he cannot know whether things might have been different for him. This has had a significant emotional impact on him. We think the Practice should recognise the impact of this with a financial remedy.

36. To determine a level of financial remedy, we have looked at ‘Our guidance on financial remedy’ which includes a severity of injustice scale. It guides us on making sure our recommendations are consistent across the complaints we look at, and transparent for everyone who uses our service.

37. We recommend that within one month of the date of this report, the Practice paysMr P £600 to recognise the distress and anxiety its mistakes caused him.

38. The Practice should send us evidence it has complied with our recommendation.