Source · SPSO (Scottish Public Services Ombudsman)

Fife NHS Board

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 201804060 Sector Health Category clinical treatment / diagnosis Decided 01 February 2021

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Full decision

Summary

C complained about a consultation with a consultant psychiatrist. During the consultation, C discussed a previous incident where their GP prescribed medication without carrying out a review of C's medical records. Following the consultation, the consultant psychiatrist recommended C be prescribed Mirtazapine (antidepressant medicine). C experienced side effects from the medication and subsequently discovered that their GP's records showed they had been prescribed this medication a number of years previously and had experienced adverse side effects. In light of this, C complained as they did not feel the consultant psychiatrist carried out an appropriate check of C's medication history before recommending that Mirtazapine was prescribed. C also complained about the time taken by the board to investigate their complaint and the thoroughness of their investigation.

In respect of C's first complaint, we took advice from an appropriately qualified independent adviser with a background as a consultant psychiatrist. We found that the course of action taken by the consultant psychiatrist was appropriate and reasonable. We recognised that the decision to recommend Mirtazapine ultimately had a negative outcome for C, but we concluded that the decision-making and process leading to this recommendation was reasonable. We considered the consultant psychiatrist took appropriate action to ensure they had enough information to make an informed decision. In light of this, we did not uphold this complaint.

In respect of the C's second complaint, we concluded that the board had carried out an appropriately thorough investigation, but their responses could have been clearer and more detailed. We also considered the time taken for the board to provide both a stage 1 and stage 2 response was unreasonable. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case: Apologise to C for not handling their complaint in a reasonable or appropriate manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended: The board should reflect on how the complaint was handled from when it was received to when the stage 2 response was issued. Consider what failings took place during the process and what learning and improvement can be put in place.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Related reading

View Decision Report 201804060 as a PDF (26.6 KB) Updated: February 17, 2021

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