Decision Report 201608902

Summary

Mr C transferred to the practice from another practice and, on first attendance at the new practice, was prescribed Sertraline (an anti-depressant medication used to treat anxiety). However, he suffered side effects as a result of this prescription. He was of the opinion that this would have been immediately obvious to the doctor he saw, had they checked with his previous GP, as Mr C had previously been prescribed this medication and had suffered side effects. He was also unhappy with the manner and tone adopted by the doctor. He complained about these matters to the practice and was further concerned by the tone and content of the response he received, which he considered to be confrontational and unprofessional.

Mr C brought his complaints to us. He complained that the practice unreasonably failed to consider his medical history before prescribing Sertraline and that the prescription of Sertraline was inappropriate due to the potential side effects. We took independent advice from a GP. We found that, in order to justify immediately prescribing Sertraline, rather than first trying therapies that did not require medication, the doctor should have documented a pressing clinical need or sought further evidence from Mr C's previous practice to ensure that this was appropriate. However, we found no evidence that this took place. Therefore, we upheld these two aspects of Mr C's complaint.

We also considered that the tone and content of both the clinical records and the practice's complaints responses, both to Mr C and to us, was inappropriate. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to sufficiently evidence the decision to prescribe him Sertraline and for failing to communicate appropriately with him. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Records should fully evidence any clinical decisions.
• Records and communication should be factual, neutral, and professional in tone and content.

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.