Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust: Part 2

Medicine is one of the main treatments for people with severe mental illness, including psychosis and schizophrenia. Taking a person-centred approach and ensuring people are taking their medicine in a safe and effective way is essential to achieving the best possible outcome. Poorly treated mental illness, because of non-adherence and/or under-prescribing or over-prescribing, can have devastating consequences for people and increase the risk of relapse and being admitted to hospital.

As part of our review of VC’s care and treatment, and the 10 cases we reviewed for benchmarking purposes, we looked at medicines optimisation for patients and how their medicines were managed.

In VC’s case, providing consistent and assertive treatment was key to managing his risk of violence as this, and in turn the risk to others, increased when his psychosis was not managed by medicine.

The MHA Code of Practice is clear that people with mental health conditions should be able to express their views and preferences about their care and treatment, including decisions about their medicine. Shared decision making can help people to understand the benefits, harms and possible outcomes of different options, and accommodating patient preference can increase people’s willingness to initiate and engage in treatments.

VC’s preferences were at the forefront in decisions around the choice of medicine and treatment regime. However, as highlighted in the section on Care planning, VC’s decisions and wishes were not always balanced with other information.

Despite the evidence that VC was symptomatic on the treatment prescribed and had been admitted to hospital on multiple occasions over a short period, there was no change in the approach to treatment. NICE guidelines are clear that people with schizophrenia whose illness has not responded adequately to treatment, should have their diagnosis and treatment reviewed to ensure it is at an adequate dosage and for the correct duration.

Similarly to our findings on care planning and discharge planning, it appears that there was no holistic approach to VC’s medicine reviews. These reviews do not appear to have connected his lack of response to treatment with the dose and type of medicine he was prescribed, or his lack of compliance with taking the medicine.

From the beginning of the 2 years, there was an obvious pattern of VC not taking his medicine while in the community. Records also show that medicine had been found in his flat, suggesting that he wasn’t taking it.

This element of VC’s case has similarities to a small number of cases from our benchmarking review. In 3 of the 10 cases we looked at, we found issues with medicines monitoring. In these instances, teams relied on self-reporting from patients, as there were no robust processes in place to ensure that patients were taking their medicines. We are unable to give a broader view as we did not look at medicines management as part of our wider review of NHFT. However, our benchmarking suggests this could have been a limited issue as the majority of cases showed good examples of CRHT teams ensuring that patients were taking medicine as prescribed.

As highlighted in the section on Engagement with VC and his family, NICE guidelines recommend the use of depot antipsychotic medicine for people who do not comply with taking oral medicines. Due to the challenges of providing consistent treatment for his illness, VC’s lack of engagement and poor compliance with medicine, there was evidence to support changing his treatment from oral medicine to a depot injection.

In 3 of VC’s inpatient hospital admissions there are references to a depot injection, but VC consistently declined this, stating that he preferred to take oral medicine. As highlighted in the section on Care planning, we are concerned that the team did not adequately balance VC’s wishes with other information they may have held and what may have been in his best interests. This could be seen as a missed opportunity, as his detention under the MHA presented the possibility of changing his medicine to be able to treat his symptoms more robustly.