Decision report 201200369

Summary

Mrs C was on medication for serious mental health problems. She registered with a new medical practice in 2011, having been stable for a number of years on an existing medication regime. However, the new practice did not obtain her medical records nor make contact with the psychiatrist who had been treating her previously.

In March 2012, Mrs C attended the practice about a non-related medical issue and saw a doctor. During the appointment, the doctor questioned the medication regime and said that Mrs C should undergo a review, as the types of medication she was on could have serious cumulative side effects if taken long term. Mrs C was upset and anxious that the doctor proposed reviewing her medication, given that she had been stable on the regime for a number of years and had had serious difficulties in achieving this stability. She was also upset by the doctor's tone and a number of comments he made during the consultation which she felt were inappropriate when dealing with a patient with mental health problems.

We found that the aims of the consultation were valid and constituted good practice. We were, however, critical that the practice failed to obtain Mrs C's medical records or to contact her psychiatrist, as she had registered with them nearly a year before. We noted that the doctor had written details of his comments in the consultation notes, and that he himself had since accepted that these may have added to her concerns. We were critical of this, and for the fact that he did not conduct an assessment of Mrs C's health at that time, although we recognised this could have been difficult given the nature of the consultation overall. On balance, however, we did not uphold the complaint as we found the aims of the consultation about which Mrs C had complained were reasonable and should have been undertaken earlier. We did, however, make recommendations to address the shortcomings we identified that took place before the consultation.

Recommendations

We recommended that the practice:

• conduct a significant event analysis in relation to Mrs C's treatment; and
• implement a procedure to ensure that all previous medical history and treatment is obtained when registering new patients.