Decision Report 201703081

  • Case ref:
  • Date:
    September 2018
  • Body:
    Highland NHS Board
  • Sector:
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Mrs C, an advocacy worker, complained on behalf of her client (Ms A) that the board failed to provide Ms A with a reasonable standard of mental health care and treatment. Ms A suffered from long term anxiety and depression and was referred for assessment at New Craigs Psychiatric Hospital. She was diagnosed with hypomania (a less severe form of the manic phase of bipolar affective disorder) and was started on the appropriate medication for this diagnosis. Three months later, Ms A was informed that she had been misdiagnosed and was advised to slowly come off the medication. The board apologised to Ms A for this error in diagnosis and acknowledged the distress the consequences had caused her. Ms A was unhappy with this response and Mrs C brought her complaint to us.

We took independent advice from a consultant in forensic psychiatry. They noted that Ms A's medical records did not detail what, if any, action was taken to explore other options to carry out a second opinion following a request from Ms A. We also found that the board unreasonably prescribed Ms A third level medication (medication prescribed if the first two are insufficient) in the first instance. Although this decision may not have been unreasonable itself, we found that the reasoning for this prescription was not clearly recorded. Therefore, we upheld Mrs C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Ms A for failing to record the justification for her prescription and for failing to document whether all reasonable options were explored in response to her request for a second opinion. The apology should meet the standards set out in the SPSO guidelines on apology available at

What we said should change to put things right in future:

  • Prescribing clinicians should be mindful of current clinical guidelines and ensure that they document decisions with sufficient detail to support the rationale for treatment options.
  • Processes should be in place to ensure reasonable requests for second opinions are met.
  • Clinical staff should keep accurate and sufficiently detailed clinical records.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Updated: December 2, 2018