Child and adolescent mental health ‘process’ review after Ramsgate teen prescribed wrong dose twice

Sarah says George Turle House presribed the wrong dosage for her son twice in a row

A review of prescribing processes at children and adolescent mental health service George Turle House in Canterbury will be carried out after complaints from a Ramsgate mum of incorrect prescriptions.

Mum-of-three Sarah Pilgrim made the complaint after discovering her son Ryan had been prescribed a 60mg dosage of ADHD medication instead of the required 50mg.

The 39-year-old says the higher dosage could have resulted in an overdose.

Ryan, 16, is diagnosed with Attention deficit hyperactivity disorder (ADHD), Autistic Spectrum Disorder (ASD), Global Development Delay and is registered as deaf with speech.

Atomoxetne is used to help to increase the ability to pay attention, concentrate, stay focused, and stop fidgeting. It is thought to work by restoring the balance of certain natural substances (neurotransmitters) in the brain.

But there can also be side effects, such as stomach upset, nausea, vomiting,tiredness, loss of appetite and weight loss and dizziness so using the correct dosage is important.

Wrong amount

Sarah says she made the complaint after George Turle House, providing child and adolescent mental health services in Kent but run by North East London NHS Foundation Trust (NELFT), prescribed the higher amount twice.

The prescription was sent to Orchard House in Broadstairs for Sarah to collect.

She said: “I put in Ryan’s prescription and when it was collected it had 60mg instead of 50mg,, I rang constantly every day, sometimes twice a day, and eventually George Turle House sent over another prescription, Yet again this was for the wrong amount and they had the incorrect name details for Ryan on it.

“When Orchard House received it they knew it was wrong and voided the prescription, getting me a handwritten one instead.

“If I was to give Ryan the wrong dosage he could overdose. It could have been dangerous as Ryan had never taken it before due to suffering weight loss on his medication. This means he has to be weighed and measured on a review because of all the side effects.

“Luckily I am very on the ball with prescriptions and I always check them. I know parents might not have the time to do that but I would say you must.”

Diagnosis

Ryan received his diagnosis three years ago but Sarah says she knew something was different from the moment he was born.

She said: “When he was a baby he would just lay and look at the ceiling with no real interest. Then at about seven months he took an interest in lights.

“When he was two-and-a half I tried to start the process for him but he didn’t get an education, health and care plan until he was six and was only finally diagnosed three years ago. We went through the mill.”

Sarah says many other parents have made similar complaints since the majority of services moved from Orchard House. NELFT have been delivering the service in Kent since  September 2017 via a contract transfer. In April 2018 a new model and service delivery for Kent and Medway was put in place.

Since the takeover there have been numerous reviews posted by parents to the NHS site complaining of a lack of contact and short notice appointments.

Review

One NHS worker said: “I have worked in the NHS for 20+ years and I have always championed the NHS as an organisation and the staff who provide the services within it. That view has been seriously challenged by the organisational and clinical competence of the services provided by NELFT to the young people of East Kent.

“At George Turle House I was amazed by the constant stream of distressed, angry and frustrated parents who turned up at reception in person desperate for an appointment, a medication review or a prescription who were told simply to go to A&E and try your luck there. There is something seriously wrong in how this service is managed, and 18 months after a new service provider was appointed it doesn’t look like it is getting any better. I will certainly be making a formal complaint to NELFT as the provider of this service and the CCG as the commissioners.”

‘Aware of concerns’

A spokesperson for NEFLT apologised and said a review of processes will now be carried out.

They said: “NELFT are unable to comment on individual cases  but we are aware of the concerns raised. We will ensure any shortfalls identified are fully addressed including a review of prescribing processes.

“We apologise for any distress caused to the family”

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