Poor monitoring of anti–psychotic drug

What happened

Mr D was prescribed olanzapine (an anti–psychotic drug) by a private consultant in 2004. Between 2005 and 2008 he had a number of appointments at the Trust with consultant psychiatrists. Although they were all aware that he was taking olanzapine, there was no reference in the records or during his appointments to the perceived benefits of the drug, and no consideration around whether Mr D should continue taking it. At the same time, he was referred to substance misuse services.

Mr D eventually stopped taking olanzapine on his own. He said that he suffered from lethargy and generally poor quality of life while taking olanzapine and said that he only turned to substance misuse in order to treat what he now thinks are side–effects of olanzapine. He said that he shouldn't have been referred to substance misuse services, because he was not a typical substance misuser, and in his view, the effects he experienced were due to the olanzapine.

The complaint was brought to us in August 2013.

What we found

We partly upheld Mr D's complaint. The Trust did not appropriately monitor Mr D's olanzapine prescription in line with established good practice for four years. This was service failure.

Mr D's referral to substance misuse was appropriate.

We considered the impact Mr D said that olanzapine had on him during this period. But, given the length of time that had passed, the many other drugs he had taken during that time, and the lack of any evidence to show that olanzapine caused these reactions, we were unable to conclude that the injustice Mr D described arose because of service failure.

Putting it right

Although there was service failure we could not establish any injustice.