Part 8 - Complaint about Cambridgeshire and Peterborough Mental Health Partnership NHS Trust (the Trust) and the Healthcare Commission (the Commission)
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Complaint about a decision to withdraw an anti-dementia drug, Aricept, from an elderly patient, about the care and treatment provided to him subsequently, and about the Commission’s review
Background to the complaint
Mr S was referred to the Trust by his GP in May 2002 because of poor memory and was seen by a Consultant Psychiatrist for Older People in June 2002. It was thought that Mr S had mild cognitive impairment but that dementia might be developing and an anti-dementia drug, Exelon, was prescribed. In July 2002 Exelon (which had made Mr S unwell) was replaced with a prescription for Aricept. Mr S attended further appointments in September and November 2002. At that stage it was intended that he would continue taking Aricept and that his mental state would be assessed by a Community Psychiatric Nurse.
By May 2003 Mr S’s GP considered that his mental state had deteriorated and asked for him to be reassessed. When Mr S was reassessed in July and November 2003 it was noted that his memory was continuing to deteriorate, that he would continue to be monitored and that the Community Psychiatric Nurse would keep in touch with his carers to discuss any concerns.
In January 2004 Mr S was seen by a Staff Grade Psychiatrist for Older People, with the result that the Aricept was stopped and Mr S was discharged to the care of the Community Mental Health Team. At this time Mr S was living in his own home and his day-to-day care was provided under a private arrangement, largely by neighbours.
Mr S had been recently widowed, but he had two adult sons who monitored his situation closely. In March 2004 Mr S’s condition had deteriorated and he was admitted to hospital. Mr S remained an in-patient until September 2004 when he was discharged to a nursing home.
The complaint to the Trust and the Commission
In July and August 2004 Mr S’s son, Mr T, complained to the Trust about a number of issues relating to Mr S’s care including: the failure to inform Mr S’s family and those caring for him about the stopping of Aricept; the lack of a care plan following that; and the fact that Mr S’s condition had been allowed to deteriorate. The Trust replied in September 2004 and provided a number of explanations as well as several apologies relating to communication with Mr T and the provision of information to him.
Mr T complained to the Commission in October 2004. In November 2005 the Commission told Mr T of its decision to refer matters back to the Trust to provide details about the guidelines used to discontinue Aricept.
In December 2005 Mr T complained to the Ombudsman. However, as the Commission had not sought independent clinical advice, we recommended that it look at the complaint again. The Commission sent its revised decision to Mr T in February 2006 advising that the clinical care given to Mr S was appropriate, that guidelines had been followed but that the Trust could have provided more information to Mr T.
What we investigated
In March 2006 Mr T complained to the Ombudsman. Our investigation covered the following concerns:
- the Trust withdrew Aricept from Mr S in January 2004 without informing Mr T, his carers, or the local social services department;
- following the decision to withdraw Aricept no care plan was devised and implemented, and the Trust failed to monitor Mr S to avoid deterioration;
- Aricept was not re-prescribed to Mr S despite the opinion of a member of Trust staff that it should be, and despite Mr T’s repeated requests;
- the Trust applied the National Institute of Clinical Excellence (NICE) guidelines strictly and without thought or consideration for Mr S’s individual circumstances;
- the Trust denied Mr T’s request for a change of consultant for his father;
- the Commission’s handling of Mr T’s complaint was inadequate.
We examined all relevant documentation concerning the case, including complaint correspondence, Mr S’s medical records, and the Commission’s papers. We also obtained clinical advice from an experienced Consultant Psychiatrist. We also took into account the relevant NICE guidelines in place at the time, ‘Technology Appraisal Guidance No 19: Guidance on the Use of Donepezil [Aricept], Rivastigmine and Galantamine for the Treatment of Alzheimer’s Disease’.
What our investigation found
Our investigation found that the Trust failed to communicate significant changes in Mr S’s treatment plan (that is, the withdrawal of Aricept) to those most closely involved in his care.
We found that the Trust did not identify and plan for the risk of Mr S’s deterioration following the decision to discontinue Aricept and also failed to ensure that Mr S was adequately monitored after January 2004.
We found that there would have been no benefit in re-prescribing Aricept to Mr S, even though this was recommended by a member of the Trust’s staff.
We found no documented evidence of any consideration of Mr S’s individual circumstances in the application of the NICE guidelines.
We found that Mr S was given the opportunity of review by an alternative Consultant Psychiatrist for Older People.
We found that the Commission did not take steps to understand Mr T’s complaint fully; failed on two occasions to take independent medical advice from an appropriately qualified person with the necessary expertise; did not provide Mr T with an adequate explanation for its decision; and failed to respond in a timely manner.
Our investigation concluded in March 2007 and partly upheld the complaint against the Trust and fully upheld the complaint against the Commission.
Outcome
The Trust had, before our investigation concluded in March 2007, already taken some action in response to Mr T’s complaints including: apologising for the lack of communication over the withdrawal of Aricept; revising their care plan approach which includes the identification and management of risk; undertaking to remind senior staff of the need for monitoring and follow-up where medication is discontinued; and a structured format for consensus meetings (which should result in proper recording of the decision-making process and factors taken into account when medication is discontinued).
As a result of the recommendations made in our final report the Trust also agreed to:
- apologise to Mr T and provide him with evidence that senior medical staff have been reminded of the importance of careful monitoring and follow-up of patients where medication is discontinued; and
- conduct an audit of consensus meeting documentation (to ensure that this format is used and that the requisite level of information is recorded).
The Commission agreed to apologise for the failings identified in our report.
