Failure to follow Mental Health Act Code of Practice

What happened

Mr B became ill while staying with his mother in a different part of the country, and was admitted to hospital to have his appendix removed. Doctors discharged him on antibiotics and soon after this he experienced prolonged insomnia and increasing agitation.

Eight days after his discharge, in extreme agitation he was taken back to the Hospital, diagnosed with an acute psychotic episode and sectioned under the Mental Health Act. He had never had any previous mental health problems.

The Hospital then transferred him several hundred miles to a mental health trust near his own home, under escort by a private security firm. When he arrived, doctors assessed him but could not find any clear physical cause for the episode. They prescribed him Olanzapine (an anti-psychotic medication) and discharged him. He had to inform the Driver and Vehicle Licencing Authority (DVLA) about the psychotic episode, and his full licence was withdrawn.

Mr B gradually stopped taking Olanzapine several months later and had very unpleasant withdrawal symptoms, including acute insomnia.

Mr B complained to us that he had suffered an allergic reaction to the medication after his appendix operation and said the Hospital failed to pick up on this. He said the allergic reaction had caused the psychotic episode which had led to his driver's licence being withdrawn. He said the Hospital told him he had been transferred to the Mental Health Trust by police escort and the Mental Health Trust did not tell him about the side effects of Olanzapine.

What we found

We partly upheld this complaint. The treatment Mr B received from the Hospital had been appropriate and when he complained, its response was largely reasonable. However, it had wrongly told him that he had been transferred to the Mental Health Trust under police escort, when it had been by a private security firm.

The Mental Health Trust acted in line with good practice in trying to reach a diagnosis about his psychotic episode, but doctors could not find what caused it. Antibiotic-related psychotic episodes are rare and we did not think it was unreasonable that the Hospital had not reported this as a possible adverse drug reaction.

However, the Mental Health Trust did not assess whether Mr B had the capacity to make decisions for himself at the time it prescribed Olanzapine. This was a breach of the Mental Health Act code of practice and caused Mr B distress. If this had been done, doctors would have given him information about the drug's possible withdrawal symptoms, and he could have decided whether he wanted to take it. However, we did not think that the Mental Health Trust would have been able to predict the severity of the withdrawal symptoms he subsequently experienced.

We thought the Mental Health Trust communicated appropriately with the DVLA when it asked for information about renewing Mr B's licence, and although there had been some delays in issuing and renewing his yearly licence, these were not the fault of the Trust.

Putting it right

The Hospital apologised for wrongly informing Mr B that he had been transported to the Mental Health Trust under police escort.

The Mental Health Trust apologised for failing to adhere to the Mental Health Act code of practice. It produced an action plan to make sure it learned from these events, and added a written note to his medical records incorporating Mr B's views on the cause of his psychotic episode.