Decision report 201101398

Summary
Ms C has been undergoing psychiatric treatment for a number of years and had been diagnosed with 'Bi-Polar Type II Rapid Cycling Mood Disorder'. In May 2010 she attended a consultation and was told that her diagnosis had been changed to 'Complex Personality Disorder'. Despite advice that the team would gradually reduce her medication, Ms C stopped taking her medication right away. She reported that this has made her feel considerably worse. She was also concerned that the board told her she needed a chaperone when attending any consultation where there would be discussion of her condition and treatment. Finally, she also complained that some of the copy clinical notes she was provided with were hand-written and illegible.

The complaint was investigated and independent psychiatric advice was obtained. At this point the difficulties of psychiatric advice were explained (that it was rarely that objective investigations, like blood tests, could be relied upon) and that changes in diagnosis were perhaps more probable in this area of medicine. It was confirmed that as an initial diagnosis had taken four years it was likely that Ms C's presentation was atypical and it was, therefore, reasonable to review her diagnosis and medication.

The investigation also showed that after an alleged incident involving Ms C, there had been significant concern expressed by a senior member of staff about his personal safety. A collective decision had later been taken by board staff that a chaperone should be present with Ms C and any practitioner when her clinical care and treatment were being discussed with her. This satisfied the board's own responsibilities to their staff while not prejudicing Ms C's clinical care.

After consideration, Ms C’s complaints were not upheld. However, the investigation confirmed evidence that the clinical notes given to Ms C after she requested them were, in part, difficult to read. In the circumstances, while upholding this complaint, it was recommended that the board should provide Ms C with a written transcript.

Recommendation
We recommended that the board:
• provide Ms C with a written transcript of the relevant notes.