Black Country Healthcare NHS Foundation Trust

4. Mr L complains about the Trust and the care and treatment he received from February to July 2022. He complains due to the Trust’s negligence he was incorrectly prescribed lorazepam 3mg (to treat anxiety and sleeping problems) instead of diazepam (to treat anxiety, seizures, and muscle spasms), it did not carry out regular reviews, and he was on lorazepam longer than necessary.

5. Mr L said he was on lorazepam for six months and when his medication was changed to diazepam, he was given a high dose of 12mg. He says he experienced symptoms of withdrawal from lorazepam, and this had affected him physically and mentally. Mr L believes he has become an addict.

6. Mr L also complains about the Practice and the care and treatment he received from February to July 2022. He states that the Practice prescribed lorazepam longer than necessary.

7. As an outcome Mr L wants an explanation for why the Trust and GP went against guidance and prescribed lorazepam for six months. He also wants financial compensation at level 5 of our severity of injustice scale.

8. In January 2022, Mr L’s GP referred him to the Trust as he complained of heightened anxiety, low mood and that his current antidepressant medication, venlafaxine, was ineffective.

9. The consultant psychiatrist at the Trust carried out a review and a care plan was agreed with Mr L to take diazepam 2mg three times a day as and when required.

10. In February 2022, the consultant psychiatrist wrote to Mr L’s GP to stop diazepam and prescribe lorazepam 1mg two to three tablets a day. From February to July 2022, the consultant psychiatrist wrote to Mr L’s GP with instructions on increasing or decreasing his medication. During this period, Mr L had regular assessment with the mental health liaison nurse.

11. On 20 July the consultant psychiatrist reviewed Mr L. Mr L raised concerns of the potential side effects of the drugs he was taking on his body. The consultant noted Mr L had been on lorazepam for six months and decided to replace it with diazepam at 5mg twice a day for four weeks, then reduce it to 2mg three times a day for four weeks and slowly taper it down.

12. On 28 July, Mr L was admitted to an inpatient ward at the hospital to monitor side effects of his medication.

The Trust

Lorazepam prescription

18. Mr L complains the Trust incorrectly prescribed lorazepam to treat his anxiety and sleeping problem and left him on this medication longer than necessary. Mr L believes it should have given him diazepam to treat his anxiety. He also complains the Trust did not carry out regular reviews. We are sorry to hear about the difficulties Mr L experienced with his medication and the distress this caused him.

19. Mr L was taking medication to manage his generalised anxiety disorder (GAD) and depression. This included venlafaxine (to treat depression and sometimes anxiety and panic attacks), and diazepam (as needed). The venlafaxine was no longer controlling his anxiety, so his GP referred him to the Trust in January 2022. Over the following few months, the psychiatry team adjusted his medications and doses. He continued to take diazepam 2mg three times a day (as needed).

20. On 11 February, the consultant psychiatrist advised the GP to stop diazepam and start lorazepam 1mg PRN (as needed). Both are benzodiazepines. NICE CG113 states that benzodiazepines should only be used for GAD as a short-term measure during a crisis, at the lowest effective dose for a maximum of four weeks, including tapering.

21. Mr L believes the Trust should have prescribed diazepam from the outset. However, the evidence shows he was already taking diazepam and reported it was no longer working for him. This led the consultant to switch him to lorazepam. Our adviser said lorazepam is commonly prescribed short-term medication to treat anxiety.

22. The consultant switched Mr L to lorazepam because he was in a crisis, with restlessness, palpitations and significant anxiety. Our adviser explained that lorazepam acts quickly and leaves the body quickly, making it effective for acute anxiety attacks. The evidence shows the plan was for Mr L to take lorazepam in the short term while the team found the right combination of medications to manage his conditions longer term. The Trust advised a two-week prescription.

23. Based on the evidence and our clinical advice, the initial decision to prescribe lorazepam was in line with relevant guidance.

24. However, the Trust stepped outside the guidance on the use of diazepam and advised Mr L continued to use this for six months, which exceeded the four-week period in the NICE guidance. We have considered whether this was justified.

25. The evidence showed that finding the right combination of medications to manage Mr L’s symptoms longer term was not easy. At various times, the clinical team tried fluoxetine (an antidepressant), a beta blocker (for anxiety), propranolol (for anxiety), promethazine (a sedative antihistamine for anxiety) and citalopram (an antidepressant), and then reintroduced venlafaxine in May.

26. Our psychiatrist adviser’s clinical view was that there were exceptional reasons in Mr L’s case to continue him on lorazepam. During this time, the evidence shows Mr L remained in crisis. Our adviser said the Trust was using lorazepam as a bridge to manage his anxiety while working to stabilise him on long-term treatment he could tolerate. NHS organisations should usually prescribe medications in line with relevant guidance. However, there are occasions when the clinical situation means it is right to do something different. When we weigh up the evidence, it shows it was right for the Trust to do that for Mr L’s lorazepam prescription.

27. The records show the adult mental health team reviewed him every month and had contact with him in between to talk through any concerns about his medication and general wellbeing.

28. A consultant psychiatrist did a full review before they advised changing any of the medications. At a review on 20 July, the Trust also acknowledged Mr L’s report that he felt the lorazepam was no longer having much effect and explained that the medication can become less effective when prescribed long term. It recognised it needed to start tapering him off the lorazepam, which we look at next.

29. When we weigh up the evidence, the Trust’s prescription of lorazepam was in line with the NICE guidance. The Trust acted outside the guidance when it continued to advise the GP to prescribe it for six months, but there was clinical justification to do this. We have found no failing in this part of Mr L’s care.

Tapering of lorazepam

30. On 20 July, the Trust agreed a care plan to stop lorazepam and to switch Mr L to diazepam to support withdrawal. Diazepam stays in the body longer than lorazepam and is often used to help people come off anxiety medication more smoothly without withdrawal. This means the Trust did not taper or gradually reduce it, but replaced it with a different benzodiazepine. Our psychiatrist adviser explained this decision was in line with the NICE CKS, which recommends switching from a short-acting drug to a long-acting one as a standard method for safe withdrawal.

31. Mr L was taking lorazepam 3mg daily (1mg three times a day), which is roughly equivalent to 30mg of diazepam. The consultant started Mr L on only 10mg of diazepam daily (5mg twice a day). So this was a significant drop of two thirds. Our psychiatrist adviser explained this meant Mr L was likely to experience withdrawal symptoms. These usually require careful management. Some people can handle bigger dose reductions at the beginning, but need much smaller, slower reductions at the end. The evidence shows the Trust managed the switch poorly.

32. Our psychiatrist adviser said that based on the clinical situation, the Trust should have started Mr L at 30mg of diazepam, or gradually reduced lorazepam while introducing diazepam to smooth the transition.

33. The Trust later recommended increasing Mr L’s diazepam dose, to 5mg daily plus 2mg at night (12mg). This was still significantly below the equivalent dose (30mg) he had been taking of lorazepam previously.

34. Mr L has told us he was concerned the Trust started him on too high a dose of diazepam when it stopped his lorazepam. However, the evidence shows the opposite - the starting dose of diazepam was lower than would typically be expected in this case.

35. When we weigh up the evidence, the Trust did not manage Mr L’s change of medication from lorazepam to diazepam in line with the relevant guidance. We have therefore found a failing in this aspect of his care.

Impact

36. Mr L has told us he experienced severe withdrawal symptoms including heightened anxiety, palpitations, insomnia and agitation. He attended the emergency department at a local hospital on 21 July, where he was monitored for eight hours and told he had withdrawn from lorazepam. He also voluntarily admitted himself to Bushy Fields Mental Hospital for one night due to ongoing side effects. On 30 October, he was again admitted to hospital following referral by the mental health crisis team due to benzodiazepine withdrawal.

37. We recognise that experiencing these withdrawal symptoms would have been extremely distressing and unsettling for Mr L. We have thought about whether we can say he would have avoided these experiences if the Trust had not made a mistake.

38. The NICE CKS says around 40% of people who take benzodiazepines continuously for more than six weeks have withdrawal symptoms. For short-acting drugs such as lorazepam, symptoms can begin within 24 hours of when it is reduced or stopped. Maximum intensity typically occurs between three and 14 days but may continue for up to six weeks. Up to 15% of people experience a protracted withdrawal syndrome, particularly those on long-term therapy.

39. We cannot say that lorazepam is wholly responsible for Mr L’s withdrawal-type symptoms. An inadequate dose of diazepam meant Mr L was at increased risk of experiencing withdrawal symptoms. However, withdrawal from benzodiazepines can mimic the original anxiety disorder, making it hard to separate a relapse from genuine withdrawal. The NICE CKS advises that withdrawing treatment often makes anxiety and depression worse.

40. In Mr L’s case, several additional factors likely compounded his symptoms: ongoing stress, difficult life events, and pre-existing mental health difficulties. People with severe anxiety, depression, and panic disorder traits also face a higher risk of more severe withdrawal symptoms, all of which applied to Mr L. The evidence shows it is more likely than not that the Trust’s poor management of the transition from lorazepam to diazepam caused withdrawal symptoms, particularly those that led him to go to hospital within 24 hours of the change. His ongoing symptoms were made worse by, and cannot be fully separated from, his underlying mental health conditions, so we cannot say he would have wholly avoided them if the Trust had managed the medication transition better. But its mistakes mean he cannot be reassured it did everything it could to make what may have always been a difficult and distressing transition as smooth as possible.

41. Our recommendations are set out later in this report.

The Practice

42. Mr L says his GP had a level of responsibility in his case and failed to recognise that he was on lorazepam longer than necessary.

43. BMA guidelines explain a shared care agreement is where a specialist initiates medication and shares responsibility for ongoing prescribing and monitoring with the GP. There was an informal shared care agreement in place between the GP and the Trust for Mr L.

44. The NHS GP at hand updated guidance explains that legal responsibility for prescribing lies with the doctor or health professional who signs the prescription. It is the responsibility of that prescriber to prescribe within their own level of competence. The GMC says doctors must only prescribe when they have adequate knowledge of the patient’s health and are satisfied the treatment will meet their needs. The BMA guidelines also recognises that GPs are entitled to rely on specialist advice in complex mental health cases, provided they are satisfied the prescription is appropriate and they have enough information to proceed safely.

45. Both the Trust and the Practice were involved in Mr L’s care, and the care was shared between them even though there is no formal shared care agreement.

46. The records show that the Trust and the Practice communicated well regarding Mr L’s care. The GP had good knowledge of his mental health issues, had referred him to the appropriate specialists and followed the Trust’s clear advice regarding which medication to provide. Throughout Mr L’s care, his medication changed several times. The Practice received instructions from the Trust on each occasion and implemented them. At times, the Practice rejected instructions when it felt it was not appropriate to issue a prescription.

47. On 21 February 2022, the GP discussed the risk of dependency with Mr L. The Practice also limited prescriptions to two-week supplies to monitor usage, as a safeguard. Our GP adviser said the evidence shows the Practice’s management and prescribing of lorazepam was in line with the GMC guidance on prescribing on each occasion.

48. We are sorry to hear about the distress Mr L experienced. Having reviewed all the evidence, including medical records and clinical advice, we find the Practice appropriately followed specialist advice, discussed the risks with Mr L, and monitored his prescriptions closely. We have found no failing in the care the Practice provided.

Recommendations for the Trust

49. In considering our recommendation, we have referred to our ‘Principles for Remedy’. These state where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

50. Our principles say public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.

51. Mr L told us he wanted two things. First, he wanted to understand why the Trust prescribed him lorazepam for six months. We have explained above why that was. He also wanted a financial remedy at level 5 of our severity of injustice scale.

Recommendation 1

52. Our principles state public organisations should put things right and if possible, return the person affected to the position they would have been in if the poor service had not occurred. if that is not possible, they should compensate them appropriately.

53. Mr L believes the Trust’s mistakes caused him significant mental health symptoms for 18 months. The evidence does not show that. But we do think they caused him some immediate withdrawal symptoms and contributed to longer-term symptoms. They also caused him distress because it cannot reassure him it did everything it could to make this as easy a process as possible. We have reviewed other cases where failings have caused a similar level of injustice. We think this aligns with level 2 of our severity of injustice scale.

54. Within one month of the date of our final report, the Trust should write to Mr L to acknowledge what it got wrong and pay him £250 to recognise the impact of this.

Recommendation 2

55. Within two months of this final report issue date, the Trust should create an action plan to set out what learning it will take from this complaint around the management of medication changes. This should explain what it will do, or already has done, to make sure it does not repeat the same failings, who is responsible for each action, when it will or did complete the action, and how it will monitor the success of this.

1. We are sorry to hear of Mr L’s concerns and the impact this had on him. We have carefully considered his complaints. Based on the evidence we have seen, it was right for the Trust to prescribe lorazepam for as long as it did, to manage his unstable mental health. But we do not think the Trust properly managed his medication when it stopped his lorazepam. Whilst it is not wholly responsible for Mr L’s symptoms, as his underlying mental health condition also played a significant role, it did contribute to him having withdrawal symptoms and caused him distress.

2. We therefore partly uphold the complaint about the Trust. We have set out our recommendations below.

3. We do not uphold the complaint about the Practice. The evidence we have seen shows it acted in line with relevant guidance in its involvement in Mr L’s care.