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Case ref:201200942
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Date:February 2013
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Body:Greater Glasgow and Clyde NHS Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment; diagnosis
Summary
Mr C complained about the board on behalf of his daughter (Miss A) who had been referred to the board's Child and Adolescent Mental Health Service (CAMHS) when she was 15. Mr C and his wife attended some of the consultations with her. Miss A was prescribed with fluoxetine (a medicine used to treat a variety of mental health problems) and subsequently discharged from the service.
Four years later, Miss A was diagnosed with bipolar disorder (a condition affecting a person's moods). Mr C considered that CAMHS should have diagnosed this when Miss A saw them four years earlier. He complained to us that that the assessment and treatment package provided by CAMHS did not meet his daughter's needs and that that they did not listen to him and his wife.
Our investigation included taking independent advice from one of our medical advisers. We upheld part of Mr C's complaint, as we found that the treatment provided to Miss A by CAMHS was reasonable, but that there were a number of deficiencies in the records. In particular, there was no record of the action taken by the psychiatrist who briefly saw Miss A and no record of any formal mental state examination. Staff also failed to explicitly state the diagnosis, treatment plan and prognosis. However, the records made at the time indicated that the clinicians had listened to and reported the concerns of Miss A's parents while she was being seen by CAMHS. There was no indication that Miss A showed any symptoms or signs that were specific to the diagnosis of bipolar mood disorder at that time and there was no reason to diagnose this. The only diagnosis that appeared to be applicable during that period of assessment was of a depressive disorder. Given this, bipolar mood disorder would have been a risk for the future, but one amongst a number.
Recommendations
We recommended that the board:
- issue a written apology for the deficiencies in Miss C's records; and
- review the record-keeping in CAMHS to try to ensure that such failures are no longer occurring.