Estimated read time: 4 mins
Ms N, a 32-year-old psychiatric nurse, had been off work for several weeks following an argument with another member of her team.
She self-referred privately to see Dr B, a psychiatrist, with whom she had previously worked closely. She explained to Dr B that her alcohol intake had recently increased, and she had become unusually restless, with a reduced need for sleep. She had also been spending more money than usual and had been getting into fights with her partner and sometimes with strangers.
At the consultation she said that in the past she had experienced similar episodes of increased activity and also reported periods of low mood. She had described herself as ‘moody’ but had never considered this sufficiently serious to seek referral to a psychiatrist. Dr B made a diagnosis of bipolar disorder, currently hypomanic. Ms N agreed to start pharmacological treatment.
Ms N and Dr B had a long conversation about the treatment of bipolar disorder and Ms N was prescribed sodium valproate, a mood stabiliser.
At the next consultation her sleep was improving and her hypomania appeared to be reducing. However, she soon started to complain of low mood and Dr B decided to prescribe lamotrigine, in addition to her valproate, as a treatment for bipolar depression.
Ms N was familiar with both sodium valproate and lamotrigine as treatments for bipolar disorder and was taking precautions to avoid pregnancy as valproate is a known teratogen.
The symptoms of Ms N’s depression persisted, and she had still not returned to work. As a result, Dr B suggested that they should increase the dose of lamotrigine. Ms N was concerned about the impact a history of psychiatric disorder would have on her employment. As a result, she sought to put pressure on Dr B to limit what was documented in her records.
Unfortunately, as a result of the increase in the dose of lamotrigine, Ms N developed a severe form of Stevens-Johnson syndrome and spent some time seriously ill in intensive care.
The conversation about the increase of lamotrigine dose, and any discussion of possible side effects, was poorly recorded. It is unclear whether the possibility of developing Stevens-Johnson syndrome was touched on - Dr B had some recollection of the exchange but had not written it down.
Dr B remembered thinking that she did not want to patronise Ms N, as she thought Ms N was usually extremely competent at her nursing job.
Following her time in the ICU, Ms N was unable to return to work and she made a claim against Dr B.
Dr B contacted Medical Protection for assistance and the legal team instructed a psychiatry expert to examine the case. The expert was critical of Dr B’s management of Ms N’s drug regime, as there is a known high risk of developing Stevens-Johnson syndrome when sodium valproate and lamotrigine are combined – a risk that increases with dose.
Because of the critical expert report, it was felt that the claim could not be defended. It was settled for a modest sum
Select the correct statements from the options below:
When consenting a colleague you can justifiably take it for granted that they are well informed and your obligation of disclosure is less than usual.
It is good practice to not treat people too close to you, either relatives or colleagues.
Patients should receive assurance about confidentiality and if they are not satisfied, alternative arrangements can be made.
There is a known risk when combining sodium valproate and lamotrigine
Which of the statements below is best practice:
Well-informed patients do not need explanations of side effects
Patients should always be treated by colleagues or friends
It's safer to assume no prior understanding, even for well-informed patients
It’s unnecessary to document conversations about treatment with patients
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