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Maintaining momentum: driving improvements in mental health care

The complaints we see: diagnosis and failure to treat

The complaints below are representative of the failings we see connected to diagnosing mental illness and the subsequent impact of not providing the treatment or support for the individual’s needs.

The case of Ms J shows the importance of considering and treating a physical illness when someone is in a mental health setting and the terrible consequences that can occur when this does not happen. The Five Year Forward View for Mental Health recognises this, committing to both improving staff awareness of mental health in physical health settings, as well as funding physical health checks for people with severe mental illness.

The case of Mr O shows the importance of fully exploring the issues an individual raises when assessing them. Not doing so can lead to a missed diagnosis and a failure to provide someone with the appropriate support and treatment. As Mr O’s case illustrates, this can lead to the most tragic of outcomes. Suicide prevention is highlighted as a priority in the Five Year Forward View for Mental Health, as is the need for additional skills and capacity in the workforce. We welcome this focus.

Ms J

What happened

Ms J was diagnosed with bipolar affective disorder during a period travelling in Australia. On her return to the UK, her GP referred her to the Trust, which allocated her a care co-ordinator. She was seen by her care co-ordinator and other staff from the Trust and the medication she had been prescribed in Australia was gradually reduced then stopped.

Some months later, Ms J had a further psychotic episode, was admitted to hospital and prescribed antipsychotic medication, which she refused. This medication was then administered by injection. Over the next few days, Ms J continued to be treated with antipsychotic medication and her condition appeared to improve.

She reported some physical symptoms to staff, including high pulse rate, stiffness and a sore back. She was later found to be disoriented and confused, glazed in expression and stiff. Her mental state deteriorated again.

Doctors put the increased confusion down to infection and treated it with antibiotics. A CT scan1 was also taken. Ms J’s physical symptoms persisted, and doctors continued to treat her for an infection.

Ms J was later found dead. The coroner recorded that Ms J died from Neuroleptic Malignant Syndrome (NMS), a rare but potentially life-threatening reaction to the use of a group of antipsychotic drugs or major tranquilisers called neuroleptics.

What we found Early on in Ms J’s care, when she had a temperature and high pulse rate, it was recorded that NMS was unlikely. When, after a few days of improvement, Ms J’s mental state deteriorated and she reported further physical symptoms, the doctors responded by testing for a urine infection and treating this with pain relief and antibiotics.

The doctors treating Ms J also looked at other possible causes for the change in her condition, and ordered a CT scan, but did not consider NMS. As doctors were struggling to determine the cause of Ms J’s symptoms, they should have referred her for a physical medical opinion, but did not.

Staff did not carry out a creatine phosphokinase (CPK) blood test, which would have identified NMS.2 This was contrary to Good Medical Practice, which advises that good clinical care must include adequately assessing a patient’s condition and providing or arranging the advice, investigations and treatment that are needed.

Had doctors identified NMS, it is likely that Ms J would have received the appropriate treatment and survived. As such, we concluded that Ms J’s death was avoidable. Furthermore, we found that the Trust was not open and accountable or customer focused in its response to Ms J’s mother’s complaint, adding to the distress felt by the family.

Our recommendations

We recommended the Trust write to Ms J’s mother to fully acknowledge and apologise for the failings we identified and to outline the lessons learnt and the actions that would be taken as a result of our findings.

The Trust, in its response, said it had:

  • Ensured all medics receive peer supervision to discuss challenging clinical cases, monitored through audit reports.
  • Sent a high profile alert to its staff raising awareness of NMS and started including information about the condition in inductions for trainee medics.

Mr O

What happened Mr O’s GP referred him to the Trust’s community mental health team following concerns about his mental health. Mr O had not shown any previous signs of mental ill health. His case was triaged and a recommendation made that he be seen with two workers due to the paranoid nature of his presentation.

Mr O was only seen by one Approved Mental Health Professional (AMHP)3 who decided he did not meet the criteria for referral to secondary care, but that he might benefit from short-term support to assess whether his symptoms were indicative of a developing illness.

At his next appointment, the AMHP recorded that Mr O was not suffering from a major mental disorder and discharged him to his GP. A little over a month later, Mr O took his own life. Mr O’s father, Mr E, complained about the care his son received.

What we found

The AMHP assessed Mr O as having ‘first episode psychosis’. The National Institute for Health and Care Excellence (NICE) guideline for psychosis states that healthcare professionals should assess for Post-Traumatic Stress Disorder (PTSD) because people suffering psychosis are likely to have experienced previous trauma.

Mr O had referred to childhood sexual abuse in his assessment, meaning it would have been appropriate to explore PTSD. The AMHP did not explore the possibility that Mr O was suffering from PTSD or use any recognised assessment tools, such as the Impact of Event Scale, which measures the distress caused by traumatic events.

Therefore, we found the Trust had failed to follow clinical guidelines and recognised practice when assessing Mr O and failed to explore a potential diagnosis for PTSD. As a result, the risk assessment conducted by the Trust was too brief and inadequate because there had been no consideration of the risk posed by PTSD.

Mr O was then referred for Cognitive Behavioural Therapy, which was inappropriate for his symptoms and not in line with the treatment options for psychosis as set out in the Mental Health Clustering Tool.4

The Trust also failed to seek advice from a psychiatrist. We found that Mr O should have been assessed for and given specialist treatment for PTSD.

While we cannot say that he would have engaged with this treatment, or that this treatment would have prevented his death, missing this potential diagnosis meant that Mr O did not get the support he needed.

Our recommendations

We recommended the Trust acknowledge and apologise for the failings we identified, and develop an action plan to address those failings. We are still to close this case as the Trust has failed to provide a sufficiently robust action plan which meets the requirements we set out.

As well as continuing to press the Trust for a more rigorous action plan, we have shared this information with the Care Quality Commission so that they can consider it as part of their regulatory and inspection processes.


1 Computerised tomography scan, which produces detailed images of internal body structures, including internal organs, blood vessels and bones.

2 Creatinine phosphokinase (CPK) is an enzyme in the body. It is found mainly in the heart, brain and skeletal muscle. In NMS the level of CPK in the blood will be raised.

3 AMHPs exercise functions under the Mental Health Act 1983. Those functions relate to decisions made about individuals with mental disorders, including the decision to apply for compulsory admission to hospital. Social workers, mental health and learning disabilities nurses, occupational therapists and practitioner psychologists, registered with their respective regulator, may train to become AMHPs. Read the Approval criteria for mental health professionals.

4 The Mental Health Clustering Tool allows clinicians to identify appropriate treatment options for a patient based on their presentation.