Clinical treatment outside hospital; GP : A GP Practice in the area of Aneurin Bevan University Health Board

The investigation considered Ms A’s complaint about her treatment by a GP Practice (“the Practice”), in the area of Aneurin Bevan University Health Board (“the Health Board”).

Ms A said she reported to the Practice’s Advanced Mental Health Nurse Practitioner (“AMHNP”), on 15 October 2020, that she was experiencing an adverse reaction to sertraline (a type of antidepressant). However, the AMHNP failed to advise her to discontinue the medication or act upon the deterioration in Ms A’s mental health. Ms A said that the AMHNP failed to schedule a follow-up appointment and arrange blood tests to investigate her symptoms. Ms A said that the AMHNP did, in due course, advise her to discontinue sertraline, but this was done rapidly and she developed symptoms as a result of the discontinuation. Ms A said that the AMHNP failed to acknowledge and respond to her mental health crisis and reacted to her having an aggressive outburst by calling the Police and escorting her from the Practice. Ms A said she was removed from the Practice with immediate effect and considered this response to be inappropriate and unwarranted as her outburst was a manifestation of her illness.

The investigation found that Ms A was exhibiting symptoms of depression on 15 October and it was therefore appropriate not to discontinue sertraline. It was also reasonable for a definitive follow-up date not to be booked following the 15 October appointment. The AMHNP was not directed to arrange blood tests by the GP and therefore she could not be criticised for not doing so. The Practice was however, invited to remind the GPs of the obligations placed upon them by the General Medical Council’s ethical guidance for doctors. The clinical decision to cease the prescription of sertraline by gradual reduction on 1 December was appropriate. Whilst the speed of reduction was not in line with the prescribing guidance the impact of the side effects from continuation over a longer period was likely to have been clinically worse for Ms A than the discontinuation side effects.

There was no evidence within the clinical records of a discussion between the AMHNP and the GP prescriber before reducing the sertraline dose. In addition, there was no evidence of a discussion between the AMHNP or the GP prescriber about advising Ms A about the side effects she may encounter during the withdrawal; Ms A suffered an injustice as a consequence of this failure as she was unprepared for the short term effect that the withdrawal would likely have upon her. The investigation found that Ms A displayed aggressive behaviour on 15 December, staff were concerned for their safety and the police were appropriately called. Finally, the investigation found that the correct procedure was followed in removing Ms A from the Practice list, however, in the future the Practice would notify patients of the decision before being informed of their removal by the Health Board.

The Practice agreed to apologise to Ms A for the failures identified. It also agreed to reflect on the failures and observations in the report and to remind all staff of the importance of good record keeping in relation to discussions between prescribers and staff. The AMHNP was invited to reflect on the findings of the report at her next annual appraisal.