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The Psychological Effects Of Clinical Negligence: First Look At The Records

In this first of a two-part series, Professor Walter Busuttil,
consultant psychiatrist at Expert in Mind, looks at some cases
which document the effects on mental health caused by
physical health clinical negligence.

I have found over the years that it is really important to read the letter of instruction from the solicitors very carefully and to work out and understand exactly what they’re asking of me. If the request is not clear, pick up the phone and discuss with the instructing solicitors.

One will obviously need to know whether the instruction comes from a claimant’s solicitors or defendant’s solicitors or whether you are being jointly instructed.

Usually, the letter of instruction will contain a summary of the case, which is important as a guide for one to understand what is going on.

So, there could be a whole series of events that occurred in relation to a medical clinical negligence case where, for example, a surgical operation went wrong, and the solicitors require your opinion as the appointed medicolegal expert psychiatrist or psychologist as to whether or not a mental illness has occurred as a result of the alleged negligence. Would this mental illness have happened in any case because of the nature of the operation?

Of course, in reflecting carefully about the case, one will need to think about predisposing factors, precipitating factors, and maintaining factors. These are issues of causation from a legal perspective. 

From a predisposition point of view, a past psychiatric history or family history of mental illness could be important, as well as exposure to previous trauma or significant life events or similar events.

As far as maintaining factors are concerned, it is important to bear in mind the resultant long term physical health of the patient post the alleged negligence. Will there be chronic pain, or scarring, or disability ascribed to the negligence which is only present but for the negligence? These factors may be maintaining factors which trigger the mental illness prognostically. One will need to consider what other experts are saying about the physical health prognosis as there will be an impact on the long-term mental health prognosis. One may consider recommending treatment interventions which are coordinated with physical health recovery such as antidepressant medications that treat depression as well as chronic pain.

The solicitors will usually send a bundle of clinical records, including the general practice records and possibly hospital records, as well as other expert medicolegal reports. In addition, they may include a letter of claim and the response letter rebutting the claims from the defence.

In my own clinical practice preparing medicolegal reports, I would normally read and summarise all relevant parts of the documents. I would start with the letter of instruction, and the letters of claim and defence, moving on to the general practice records and hospital records and finishing with the expert medicolegal reports. I would make written summaries of important entries within each document. I would make a note of the date and the page of each entry relevant to the case. I find that this process always gives me a good insight and understanding of what is going on. I usually start chronologically with the general practice records as they give a broad idea of the lifelong clinical history of the individual. I usually start with the consultation Lloyd George handwritten records and then go on to summarise the electronic consultation records. I would also consider the electronic summaries and medication prescribing records, which allow a bird’s eye view of physical and mental illness over many years, as well as medications prescribed to treat and the frequency of these prescribed medications. Following this, I would summarise the letters of correspondence. Then I would read and make handwritten notes of the hospital records, excluding anything already summarised within the General Practice records and anything that was not relevant from a mental health perspective. Lastly, I would read and make notes from the expert medicolegal reports. To keep track of the important entries in all these records, I usually prepare a brief handwritten note of each relevant entry together with the date and page number on the bundle.

Following this, before seeing the patient, I would dictate what will be the second part of my report – the ‘Evidence from the Documentation Provided’ by following the notes I have made and referring to the entry of each note in the bundle. This process I find gives me a second run at the records and allows me to analyse the importance and relevance of each entry.

In this way, before seeing the patient, I would have a very good idea not only of what has happened, but a clear idea of the clinical framework that the index events or event actually fit into. So, for example, if there’s a prior chronic history of depression documented in the clinical records predating the index event or a history of childhood trauma predating the index event, I have a better handle on how relevant and important these potentially predisposing factors are.

In my next instalment I will talk a bit about the actual assessment of the patient and easy ways to go about this.

Shocking waiting lists across the UK for ADHD diagnosis

NICE Guidelines state that no one should wait longer that three months between being referred for an ADHD Assessment and being seen, but from the abundance of media coverage and statistics out there, it is clear this is sadly not the case across the United Kingdom. We looked at some of the wait times and the results are shocking. Here are just a few examples:

Leeds and York NHS Trust

The Leeds and York NHS website advised last month that they typically receive 195+ referrals per month which exceeds their capacity by far. As of January 2024, they noted approximately 4,000 people on the waiting list. Those being assessed currently joined the waiting list in January 2021 – a 3 year wait.

They further note that “This waiting period is accurate for those at the front of the waiting list but will be several years longer for those who have been referred more recently. Due to the gap between demand and capacity, this waiting time is expected to increase.” Diagnosis is not the only worry; Leeds and York NHS Trust further report that there were, in January 2024, approximately 290 people on their ADHD medication waiting list; those being booked currently having waited since December 2021, a staggering 2 years and 4 months wait. This is an excruciatingly long wait between receiving diagnosis and being started on medication.

Devon NHS Trust

Advice on the Devon NHS website, updated in February 2024, states they are seeing people who were referred in July 2021 – a wait time of approximately 2 years and 7 months. A slight reduction in comparison to Leeds and York NHS, but only marginally. On the plus side, the wait for medication is slightly lower promising 18 months with those being referred in October 2022 currently being seen.

Central and Northwest London NHS Trust

The Central and Northwest London NHS website advises that since November 2023 they have had to close their waiting list.  Due to receiving extremely high numbers of referrals they are at capacity. Astonishingly, their current wait time is over 36 months, for those that managed to get on the waitlist prior to closing.

It was reported by the BBC in March last year that “Assessments for attention deficit hyperactivity disorder (ADHD) can take longer than five years in Sussex and up to four years in Surrey, data from health bodies show.”

In the last couple of weeks the BBC have reported “NHS cannot meet autism or ADHD demand, report says”. Quoting an average of one to two year wait times for ADHD assessments for 24% of patients and a 51% increase in demand for prescriptions for ADHD medications since 2019.

Autism Spectrum Disorder Assessments

As well as looking at the significant waiting times for ADHD assessments, it is important to highlight the significant waiting times for Autism Spectrum Disorder assessments. According to the statistics, 50-70% of individuals that are diagnosed with ASD also have ADHD present. This translates into approximately 25% of those diagnosed with ADHD also having ASD; although it is thought between clinicians that this is much higher, yet undocumented.

The latest NHS figures report, the highest ever recorded figure, 172,000 adults and children that are on waiting lists for an ASD assessment and it seems reasonable to assume that this is only set to rise based on the growth in figures over the last few years. With the report “A country that works for all children and young people: An evidence-based plan for addressing the autism assessment and support crisis” reporting that since Covid-19 there has been a 306% increase in the number of children waiting for an autism assessment.

The Devon NHS website advises that, as of February 2024, the current wait time was approximately 5 years and 6 months for an ASD Assessment, with patients being initially referred in August 2018 currently being assessed. With NHS ‘experimental’ data showing that, as at June 2023, 143,119 people were waiting for an autism assessment. With this number rising to 157,809 on the waiting list by September 2023. The September report also depicts a worrying picture, noting that the number of diagnoses were actually down by a third against the previous year. With only 754 patients being diagnosed in the month of September 2023 in comparison to 1,058 in September 2022. With a 27% rise in new referrals being reported over the same period it is difficult to see these numbers reducing in the near future.

The Nice guidelines timeframe of being seen within 3 months of referral is completely lost here, with only 6.4% of patients getting an appointment for assessment within 13 weeks of referral being reported in the September 2023 statistics.

The request for evaluations for autism and ADHD has surged so rapidly that existing services are overwhelmed. Heightened recognition of neurodiversity, combined with staffing challenges, the effects of the pandemic, and persistent financial shortfalls, have resulted in escalating delays and extended wait periods that detrimentally impact individuals’ daily experiences.

The consequences for children are profound. Lacking an official diagnosis, children and adolescents who may have autism or ADHD often do not receive necessary assistance in educational settings, potentially altering their future path significantly.

This eye watering situation is part of the reason why we opened The ADHD Clinic. We want to ensure that people have access to ADHD Assessments, from a team of highly experienced specialists, within the recommended timeframe.  We offer an Adult ADHD diagnosis within 6-8 weeks and a Child ADHD diagnosis within 14-16 weeks[1], with the added benefit of a multidisciplinary assessment option with both a psychologist and psychiatrist to give a holistic and fully encompassing diagnosis. We are also pleased to be able to offer a Fastrack ASD assessment option.

[1] Timescales correct at time of writing but are subject to change.

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