Trust gave mental health patient too much medication too quickly

What happened

Mrs N was an inpatient at a psychiatric hospital. She was suffering from distressing hallucinations, and staff prescribed an antipsychotic medication to reduce her distress. Doctors prescribed an initial low dose, and then increased this later the same day. After she had the first dose, Mrs N became drowsy and sleepy and seemed sedated. A nurse asked a doctor whether to give Mrs N the second dose despite her condition. The doctor said that if Mrs N was drowsy or sleeping, she should not have the second dose; but if she awoke distressed by her hallucinations, she should be given the medication. Mrs N's distress continued and staff gave her the second dose in the evening.

Early the following morning, Mrs N fell while getting out of bed. Staff documented some injuries and sent Mrs N to hospital for a pelvic X–ray. This did not show a fracture, but revealed another potential (unrelated) problem. Mrs N then had a bone scan, which also did not show a fracture. Two days later, Mrs N had a CT scan, which showed she had a fractured vertebra in her lower spine.

When Mrs P complained, the Trust said that staff gave Mrs N necessary and appropriate medication and this could not account for her overall deterioration. It said there was no delay in diagnosing the fracture.

What we found

While it was appropriate to give Mrs N the antipsychotic medication, the prescription was for too much too quickly. Mrs N should not have had the second dose so soon, and especially not because she was experiencing side effects from the first dose.

The prescription was for an unlicensed use of the medication. This is common and reasonable in psychiatry but doctors should give the patient clear information about this before they give the medication. No one gave Mrs N such information. We could not say, however, that the medication caused Mrs N to fall.

There was no delay in diagnosing Mrs N's fracture. Although she had clearly suffered injury as a result of falling, those injuries did not include the fracture, which could have occurred either significantly before, or several days after, her fall.

When it responded to Mrs P's complaint, the Trust should have acknowledged that staff had given Mrs N too much medication too quickly, and that the medication was used off–label, and that Mrs N had not had all the information she needed.

It did not do this, and it told Mrs P it would take no further action on her complaint. This was inappropriate, given the clear failings it should have identified.

Putting it right

The Trust acknowledged and apologised for its failings, and paid Mrs P £1,750 compensation. It agreed to draw up an action plan showing learning from mistakes to prevent the same mistakes happening again.

A doctor involved agreed to discuss what had happened with the person responsible for his revalidation.