Decision Report 201609072

Summary

Mrs C was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD - a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness) by a private specialist, and she reported a very positive response to the medication prescribed. She had previously been seen by a consultant psychiatrist at Queen Margaret Hospital, who noted longstanding symptoms of anxiety.

Mrs C saw the psychiatrist again following receipt of the private opinion but the psychiatrist did not agree with the ADHD diagnosis and was not willing to support the recommended medication prescription. As Mrs C's GP practice would not agree to prescribing this medication without the support of her NHS psychiatrist, she was required to pay for it privately.

The board offered Mrs C a second opinion from another consultant psychiatrist, who confirmed her ADHD diagnosis and supported the prescribing of the recommended medication. Mrs C complained that the initial psychiatrist unreasonably failed to diagnose her ADHD and did not follow relevant ADHD protocols.

We took independent medical advice from a consultant psychiatrist, who considered that it was reasonable for the first psychiatrist not to have followed specific ADHD diagnostic protocols at Mrs C's initial out-patient appointment. We found that the psychiatrist's management plan following this consultation was appropriate and that it allowed for review of Mrs C's diagnosis, and specific diagnostic protocols to be considered, at future appointments.

However, the board were unable to provide any written record of Mrs C's follow-up consultation with the psychiatrist. We found that the psychiatrist appeared to only have phoned Mrs C's GP to recommend referral for a second opinion. They did not document the call and no clinic letter was produced. Therefore, we considered that there was an absence of adequate medical documentation to support the psychiatrist's diagnosis and, in particular, their rationale for disagreeing with the medical opinion of the private specialist. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the psychiatrist's failure to appropriately document details of their consultation with her, including their rationale for disagreeing with a specialist opinion.The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• Clinicians should ensure that they adhere to General Medical Council Good Medical Practice guidelines on record keeping and, in particular, they should clearly document their clinical rationale where there is a difference of opinion.

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.