A man who suffered a psychotic episode which lasted for weeks was not fully informed about potential extreme side-effects of taking steroids medication, England’s health service Ombudsman has found.
Andrew Holland was prescribed steroids in early January 2022 by Manchester Royal Eye Hospital after losing vision in his left eye and suffering a severe infection in his right eye.
The 61-year-old from Manchester was given the medication as treatment for eye inflammation, but soon began suffering from disrupted sleep and severe headaches.
These side-effects developed into more serious ones, including becoming aggressive, psychotic, and inexplicably wandering the street at different times of the day and night.
Andrew began having hallucinations of seeing people, animals, and dust on people, leaving him confused and scared after not knowing what was happening to him for a month.
After several hospital visits due to his symptoms, Andrew attended Manchester University NHS Foundation Trust’s emergency department in mid-January with a severe headache and later became an inpatient.
He was diagnosed with steroid induced psychosis, with symptoms including hallucinations, insomnia and behaviour changes.
Andrew attended the Trust again in early February, where he was described as having ‘steroid mania’ and was advised to cease taking the medication.
Later that month, he was taken to another Trust where he was described as having ‘steroid psychosis’. He was eventually discharged in mid-February after the psychotic episode ceased.
Though no failings were found with Manchester University NHS Foundation Trust in prescribing Andrew with steroids for the eye condition, the Ombudsman discovered a missed opportunity to fully inform him of potential extreme side-effects. He was therefore unable to make a fully informed decision about whether to take them or not.
The Trust apologised for an ‘unsatisfactory experience’. However, the Ombudsman found relevant guidelines were not followed. Moreover, there had been no acknowledgement of mistakes in communication about the side-effects. Nor was any attempt made to correct them.
Following the partly-upheld complaint for not informing Andrew of the potential extreme side-effects, the Ombudsman recommended the Trust pay £700 compensation in recognition of the distress and worry he experienced.
The Trust has also been asked to write to Andrew to acknowledge something went wrong in communicating the side-effects and to apologise for the distress, anxiety and upset this ultimately caused.
The Ombudsman has also recommended an action plan be produced by the Trust to address how it will learn and improve from this case.
Andrew Holland said:
“It was terrible. I went in and out of about three different hospitals.
“I don’t know what I was capable of. Apparently, I had the ambulance sat outside for about half an hour while I insisted on doing my ironing before I went with them. It was just crazy.
“I’m not really blaming the doctor and it’s very rare to get a reaction off them.
“I had a bad reaction and I suppose you could have a reaction to any kind of pills.
“I was seeing all sorts. It was crazy. There was a bear at the end of the garden one day and a burglar coming over the garage roof.
“I just took what they told me to take. I wouldn’t like to go through that again and I wouldn’t wish it on anyone either.
“I want people to be aware of this that it can happen. I don’t know why it went against me but it happened. It can happen to anyone, I suppose.
“The case worker did a great job – they were fabulous. They kept me informed and told me everything that was going on.”
Rebecca Hilsenrath, Chief Executive of the Parliamentary and Health Service Ombudsman, said:
“This must have been a terrifying experience. It is an act of trust to put yourself under the care of others and trust depends on information and understanding. No one wants to suffer a psychotic episode – no one should do so as a result of medication without fully understanding and accepting the risk.
“Trust is also dependent on recognition of mistakes, and on steps being taken to ensure they are not repeated.
“This case shows the power of making a complaint and how it can prevent others from experiencing similar issues in the future.”