Archive

Tag Archives: mental-health

When a Psychiatric Diagnosis Is Uncertain, Look Beyond Psychiatry

August 19, 2026
Uncategorized
Leave a comment

Psychiatric diagnoses are often made from patterns of symptoms, behaviour, history and clinical observation. Those tools are important—but when a diagnosis is questionable, atypical, unusually severe, treatment-resistant or accompanied by cognitive or neurological changes, they should not necessarily be the end of the investigation.

A questionable psychiatric diagnosis should trigger a serious search for neurological, cognitive, metabolic and endocrine explanations.

This is not an argument that psychiatric illness is “not real,” nor that every person with depression, psychosis, bipolar disorder or another psychiatric condition needs an enormous battery of tests. It is an argument for diagnostic humility: before permanently attributing unexplained changes in behaviour, personality, cognition or perception to a psychiatric disorder, clinicians should ask whether the brain and the body’s underlying physiology have been adequately investigated.

Start with objective cognitive testing

A detailed neuropsychological or neurological cognitive assessment can provide information that a conventional psychiatric interview may miss.

Memory, attention, processing speed, language, executive functioning, visuospatial abilities and working memory can be measured systematically. Patterns of impairment may point toward neurological disease, acquired brain injury, neurodegenerative processes or other conditions that can present with apparently psychiatric symptoms.

This is particularly important when someone reports a significant change from their previous cognitive functioning. The question should not simply be, “Does this person meet the criteria for a psychiatric disorder?” It should also be, “What has happened to this person’s brain function?”

Modern neuropsychiatric assessment explicitly recognises the importance of cognitive, neurological and laboratory information in understanding difficult presentations. 

MRI should not be dismissed when the presentation is unusual

When there is a credible possibility of neurological disease or brain injury, high-quality brain MRI deserves consideration.

MRI is generally more informative than CT for many structural brain abnormalities and provides better visualisation of grey and white matter and certain deeper brain structures. Neuropsychiatric references identify circumstances such as new-onset psychosis, cognitive decline, new personality change, seizures, traumatic brain injury and treatment-refractory presentations as situations in which structural imaging may warrant consideration.

The point is not that an MRI will automatically reveal the cause. It often will not. Nor should the phrase “high-resolution MRI” become a promise that subtle psychiatric symptoms can be explained by a scan.

The point is simpler: if neurological damage or disease is genuinely in the differential diagnosis, it should be investigated rather than assumed away. NICE material on first-episode psychosis likewise recognises neurological examination and targeted laboratory and EEG investigation, with MRI or CT considered when an organic cause is suspected.

EEG deserves consideration when electrical brain dysfunction is plausible

Some neurological disorders can produce behavioural, perceptual or cognitive symptoms that can be mistaken for psychiatric illness.

Seizure disorders are an obvious example. EEG is particularly relevant where there are episodes that are sudden, stereotyped, episodic or otherwise suggestive of abnormal electrical activity. Psychiatric assessment guidance notes that continuous or ambulatory EEG can sometimes be necessary to document abnormal activity when ordinary testing does not capture an event. 

That is why, where the clinical history makes intermittent electrical dysfunction plausible, a normal short routine EEG should not automatically end the neurological investigation.

In selected cases, prolonged ambulatory or video EEG, including a 48-hour study where clinically justified may provide substantially more opportunity to capture abnormalities than a brief recording.

But this distinction matters: a 48-hour EEG should be clinically indicated, not imposed indiscriminately on every psychiatric patient. Current psychiatric guidance generally describes EEG as an investigation to use when neurological history or examination raises the possibility of a seizure disorder or other neurological process. 

Endocrine and metabolic causes should be taken seriously

The brain does not operate independently of the rest of the body.

Thyroid dysfunction, metabolic abnormalities and other systemic illnesses can produce changes in mood, cognition, energy, sleep, behaviour and mental state. Consequently, laboratory investigation belongs in the differential diagnosis of unexplained psychiatric and cognitive presentations.

There is already recognition within psychiatric practice that physical and laboratory assessment is an important component of diagnosis and management. Standard investigations can include thyroid function and metabolic testing, with additional testing guided by the individual’s presentation. The principle should therefore be:

Do not diagnose the mind while ignoring the body.

Where symptoms suggest an endocrine disorder, the appropriate endocrine investigation should be pursued rather than assuming that psychiatric symptoms are necessarily primary.

This is not “psychiatry versus neurology”

The false choice is between saying that somebody has a psychiatric illness and saying that they have a neurological illness. Sometimes the answer is both. Sometimes neither initial diagnosis is correct.

A person can have a psychiatric disorder and a neurological disorder. Brain injury can coexist with depression. Epilepsy can coexist with anxiety. Endocrine disease can produce psychiatric symptoms. Medication, substances, sleep disorders and systemic illness can complicate an otherwise genuine psychiatric condition.

Neuropsychiatry exists precisely because the boundary between neurological and psychiatric presentations is not as clean as diagnostic labels can sometimes imply. The professional literature explicitly advocates an integrated approach rather than a rigid division between “psychiatric” and “neurological” disease.

The standard should be diagnostic confidence—not diagnostic convenience

The strongest case is not for testing everyone. It is for testing appropriately when the diagnosis does not adequately explain the person in front of you.

Red flags might include:

  • a sudden or unusually late onset of psychiatric symptoms;
  • substantial or unexplained cognitive decline;
  • new personality or behavioural change;
  • episodes suggesting seizures or altered consciousness;
  • focal neurological symptoms or abnormal neurological findings;
  • a history of significant head injury;
  • an unusually atypical clinical presentation;
  • rapid deterioration;
  • unexpected treatment resistance; or
  • a substantial discrepancy between the psychiatric diagnosis and the person’s observed cognitive or neurological functioning.

These are precisely the sorts of circumstances in which psychiatric literature recommends considering additional medical or neurological evaluation. 

A more rigorous standard

When a psychiatric diagnosis is questionable, the appropriate response should not be to simply repeat the same psychiatric assessment until the original diagnosis appears more convincing.

It should be to expand the differential diagnosis. That may mean comprehensive cognitive testing, neurological examination, appropriate blood and endocrine investigations, high-quality brain MRI, and, when the history warrants it prolonged EEG monitoring such as a 48-hour ambulatory study.

None of these tests is infallible. None should be treated as a magical machine capable of proving or disproving a psychiatric diagnosis. And indiscriminate testing can create false positives, unnecessary anxiety and inappropriate treatment.

But the opposite error can be far more consequential: mistaking an unexplained neurological, cognitive or physiological disorder for a purely psychiatric one and never looking for anything else.

A psychiatric label should be a clinical hypothesis supported by evidence—not a reason to stop investigating.

When the diagnosis is questionable, the brain deserves to be examined, cognition deserves to be measured, electrical activity deserves to be considered, and the body’s physiology deserves to be investigated.

Good psychiatry should not fear neurological investigation. It should demand it when the clinical picture warrants it.

ROYAL COLLEGE OF PSYCHIATRISTS PARITY OF ESTEEM BETWEEN PHYSICAL AND MENTAL HEALTH REQUIRING PSYCHIATRISTS TO INVESTIGATE PHYSICAL ILLNESS WITH SAME RIGOUR EXPECTED IN ANY OTHER MEDICAL SPECIALITY: OFF-LABEL ARIPIPRAZOLE FOR ANTIPSYCHOTIC-INDUCED HYPERPROLACTINAEMIA: CLINICAL JUDGEMENT, ENDOCRINE RISK & EVOLVING LEGAL STANDARD OF CARE: https://revelationsuk.com/2025/10/29/outdated-practices/

July 5, 2026
Uncategorized
Leave a comment

This is a drug well known to us for terrible adverse reactions – severe restlessness and Akathisia, not to mention excessive expenditure on shopping.. Once again it is prescribed off- label to counteract the effects of hyperprolactinaemia caused by another, despite substantial physical health decline and metabolic issues. This drug should not be accepted as any substitute for essential pathophysiological referrals and tests when there is overwhelming evidence in terms of need. I have highlighted the very important point on appropriateness. I will also highlight applicable issues below

The use of adjunctive aripiprazole to treat antipsychotic-induced hyperprolactinaemia has become an increasingly accepted off-label strategy within psychiatric practice. Randomised trials and systematic reviews demonstrate that low-dose aripiprazole can reduce serum prolactin concentrations in many patients receiving prolactin-raising antipsychotics. Yet clinical efficacy alone does not determine whether prescribing is appropriate.

Where treatment is off-label, the patient remains prescribed a long-acting depot antipsychotic, and there is evidence of multiple endocrine or metabolic abnormalities, the clinician’s responsibilities extend well beyond correcting a biochemical abnormality. The decision engages principles of clinical governance, informed consent, multidisciplinary care and, ultimately, the legal standard of care.

The medico-legal question is therefore not simply whether aripiprazole lowers prolactin. It is whether introducing a second dopamine-modulating medicine represents a reasonable, proportionate and defensible clinical response in the individual patient.

Off-Label Prescribing and the GMC: Professional Responsibilities

The General Medical Council’s Good practice in prescribing and managing medicines and devices recognises that prescribing outside a medicine’s licence may be appropriate. However, the guidance also makes clear that such prescribing carries enhanced professional responsibilities.

The prescriber should be satisfied that:

  • sufficient evidence or clinical experience supports the proposed treatment;
  • licensed alternatives have been properly considered;
  • the anticipated benefits outweigh foreseeable risks;
  • the patient is informed that treatment is being used outside its licensed indication where discussion is practicable;
  • material risks and reasonable alternatives are discussed;
  • the clinical reasoning is documented; and
  • appropriate monitoring arrangements are established.

These obligations become particularly important when the additional medication is not treating the primary psychiatric illness but is instead intended to mitigate an adverse effect of another prescribed psychotropic medicine.

NICE and the Royal College of Psychiatrists: Treat the Whole Patient

NICE guidance on psychosis, schizophrenia and medicines optimisation consistently promotes careful review of antipsychotic adverse effects rather than reflexively adding further medication. Hyperprolactinaemia should prompt reassessment of the overall treatment strategy, consideration of dose reduction where feasible, or switching to a prolactin-sparing antipsychotic if clinically appropriate.

Similarly, the Royal College of Psychiatrists has repeatedly emphasised that in cases of people with severe mental illness experience disproportionate rates of obesity, diabetes, cardiovascular disease, endocrine dysfunction and premature mortality, the College advocates parity of esteem between physical and mental healthcare, requiring psychiatrists to investigate physical illness with the same rigour expected in any other medical specialty.

Persistent hyperprolactinaemia accompanied by type 2 diabetes mellitus, obesity, hypogonadism, osteoporosis or other endocrine abnormalities should therefore trigger consideration of broader endocrine pathology rather than being viewed solely as a medication side effect.

Depot Antipsychotics Create a Higher-Risk Pharmacological Environment

The addition of aripiprazole is particularly complex where the patient remains prescribed depot antipsychotic injections.

Depot preparations cannot be rapidly withdrawn if clinically significant adverse effects develop. Dopamine receptor blockade continues for weeks after administration, substantially reducing therapeutic flexibility.

If adjunctive aripiprazole precipitates akathisia, agitation, insomnia or behavioural deterioration, clinicians cannot immediately remove the underlying pharmacological interaction. Consequently, the threshold for introducing additional dopamine-modulating medication should arguably be higher than in patients treated solely with oral antipsychotics.

Akathisia Is Not a Minor Adverse Effect

Aripiprazole is generally well tolerated, but akathisia remains one of its most clinically significant adverse effects.

Patients frequently describe overwhelming inner restlessness, profound anxiety, inability to remain still, agitation and severe psychological distress. These symptoms can be mistaken for worsening psychosis, anxiety disorders or behavioural disturbance, potentially resulting in further inappropriate prescribing.

The literature has also associated severe untreated akathisia with treatment discontinuation, self-harm and suicidal ideation in some patients.

Where aripiprazole has been prescribed solely to lower prolactin concentrations, the emergence of akathisia fundamentally alters the balance between therapeutic benefit and clinical risk.

Appropriate management should include urgent clinical review, consideration of dose reduction or discontinuation, reassessment of the antipsychotic regimen, symptomatic treatment where indicated, and close follow-up until symptoms resolve.

Multiple Endocrine Abnormalities Should Prompt Endocrinology Referral

The presence of hyperprolactinaemia together with type 2 diabetes mellitus or other endocrine abnormalities should prompt clinicians to ask a broader diagnostic question.

Is the patient experiencing a medication side effect alone, or does the presentation reflect wider endocrine disease requiring specialist investigation?

Potential differential diagnoses include pituitary pathology, hypogonadism, thyroid disease, adrenal disorders, metabolic syndrome and osteoporosis.

Adding aripiprazole may improve one biochemical parameter while delaying diagnosis of another clinically significant disorder.

Referral to a consultant endocrinologist should therefore be strongly considered where endocrine dysfunction extends beyond isolated hyperprolactinaemia, where symptoms remain unexplained, or where long-term complications require specialist assessment.

The Legal Framework: From Bolam to Montgomery

The legal analysis of these prescribing decisions has evolved significantly over recent decades.

Bolam v Friern Hospital Management Committee [1957]

The Bolam principle established that a clinician is not negligent simply because another clinician would have acted differently, provided the decision accords with a responsible body of professional opinion.

Historically, this afforded considerable protection to prescribing decisions supported by accepted clinical practice.

However, modern medical negligence law has moved well beyond Bolam alone.

Bolitho v City and Hackney Health Authority [1998]

The House of Lords refined the Bolam principle by holding that professional opinion itself must withstand logical analysis.

Courts are not obliged to accept expert evidence merely because other clinicians support it. The opinion must demonstrate coherent reasoning and appropriately balance risks against benefits.

In practical terms, this means that merely stating “adjunctive aripiprazole is accepted practice” may be insufficient if inadequate consideration was given to endocrine disease, alternative treatment options, foreseeable adverse effects or the patient’s individual circumstances.

Montgomery v Lanarkshire Health Board [2015]

The Supreme Court fundamentally reshaped informed consent.

Clinicians are now under a legal duty to ensure that patients are informed of:

  • material risks associated with proposed treatment;
  • reasonable alternative treatment options; and
  • the option of declining treatment altogether where appropriate.

A risk is material if a reasonable person in the patient’s position would likely attach significance to it, or if the clinician knows, or should reasonably know that the particular patient would likely consider it significant.

Applied to adjunctive aripiprazole, this means patients should ordinarily be informed about:

  • the off-label nature of treatment;
  • the possibility of akathisia, agitation and insomnia;
  • the possibility that treatment may not adequately resolve symptoms;
  • alternatives such as dose reduction, switching antipsychotics where clinically feasible, observation, or referral for endocrine assessment;
  • the uncertainties associated with adding another psychotropic medicine.

Failure to discuss these matters may expose clinicians to criticism even where prescribing itself was pharmacologically reasonable.

Documentation: The Clinician’s Strongest Defence

In medico-legal practice, contemporaneous documentation frequently determines whether a prescribing decision can be defended.

The medical record should clearly demonstrate:

  • why adjunctive aripiprazole was preferred over alternative strategies;
  • evidence supporting off-label prescribing;
  • informed consent discussions;
  • endocrine and metabolic assessment;
  • monitoring plans;
  • review arrangements;
  • contingency planning should adverse effects emerge.

Documentation should reflect a process of clinical reasoning rather than simply recording a prescribing decision.

Conclusion

Adjunctive aripiprazole remains a legitimate therapeutic option for selected patients with antipsychotic-induced hyperprolactinaemia. However, legitimacy does not eliminate professional responsibility.

Current GMC guidance, NICE recommendations and Royal College of Psychiatrists policy all point towards careful assessment, shared decision-making, systematic physical health monitoring and multidisciplinary management.

The legal authorities of Bolam, Bolitho and Montgomery reinforce these professional duties by requiring that prescribing decisions are supported by logical clinical reasoning, informed by responsible practice, and accompanied by meaningful patient involvement.

Where a patient receiving depot antipsychotic treatment develops persistent hyperprolactinaemia alongside diabetes mellitus or other endocrine abnormalities, the question should not simply be how to suppress prolactin. The more important question is whether the patient requires comprehensive endocrine investigation before additional psychotropic medication is introduced.

In many such cases, early referral to a consultant endocrinologist, combined with a multidisciplinary review of the antipsychotic regimen, is likely to represent the most clinically robust and the most legally defensible course of action.

THE DANGER OF OFF LABEL PRESCRIBING: FEATURING ARIPIPRAZOLE AND IMPORTANCE OF PATHOPHYSIOLOGICAL TESTING AND REFERRAL TO AN ENDOCRINOLOGIST

June 30, 2026
Uncategorized
Leave a comment

It is extremely concerning that this drug is viewed by some psychiatrists to be an acceptable substitute for proper referral to see a Specialist Endocrinologist, especially when this drug, tried before had adversely affected behaviour and metabolism being a poor/non metaboliser ignored. This, combined with Clopixol Depot is hardly a suitable substitute for proper referrals in relation to physical healthcare. My blog “Outdated Practices” spells the need for rigorous care in terms of treatment which is what Precision Psychiatry is all about – patients under the MH deserve the very best of care yet this is not happening in the UK. Precision Psychiatry therefore needs to be mandatory to ensure that when a patient is not responding to treatment and has underlying physical health issues, that specialist referral is made to an Endocrinologist, neurologist, immunologist. Something needs to be done about this very urgently to stop mental health patients from being harmed. I shall post further example of the known effects of Aripiprazole which I doubt was ever informed in the circumstances. It is only right that patients are properly informed.

https://revelationsuk.com/2025/10/29/outdated-practices/

Off-Label Aripiprazole for Antipsychotic-Induced Hyperprolactinaemia: Clinical Judgement, Endocrine Risk and the Evolving Legal Standard of Care

The use of adjunctive aripiprazole to treat antipsychotic-induced hyperprolactinaemia has become an increasingly accepted off-label strategy within psychiatric practice. Randomised trials and systematic reviews demonstrate that low-dose aripiprazole can reduce serum prolactin concentrations in many patients receiving prolactin-raising antipsychotics. Yet clinical efficacy alone does not determine whether prescribing is appropriate.

Where treatment is off-label, the patient remains prescribed a long-acting depot antipsychotic, and there is evidence of multiple endocrine or metabolic abnormalities, the clinician’s responsibilities extend well beyond correcting a biochemical abnormality. The decision engages principles of clinical governance, informed consent, multidisciplinary care and, ultimately, the legal standard of care.

The medico-legal question is therefore not simply whether aripiprazole lowers prolactin. It is whether introducing a second dopamine-modulating medicine represents a reasonable, proportionate and defensible clinical response in the individual patient.

Off-Label Prescribing and the GMC: Professional Responsibilities

The General Medical Council’s Good practice in prescribing and managing medicines and devices recognises that prescribing outside a medicine’s licence may be appropriate. However, the guidance also makes clear that such prescribing carries enhanced professional responsibilities.

The prescriber should be satisfied that:

  • sufficient evidence or clinical experience supports the proposed treatment;
  • licensed alternatives have been properly considered;
  • the anticipated benefits outweigh foreseeable risks;
  • the patient is informed that treatment is being used outside its licensed indication where discussion is practicable;
  • material risks and reasonable alternatives are discussed;
  • the clinical reasoning is documented; and
  • appropriate monitoring arrangements are established.

These obligations become particularly important when the additional medication is not treating the primary psychiatric illness but is instead intended to mitigate an adverse effect of another prescribed psychotropic medicine.

NICE and the Royal College of Psychiatrists: Treat the Whole Patient

NICE guidance on psychosis, schizophrenia and medicines optimisation consistently promotes careful review of antipsychotic adverse effects rather than reflexively adding further medication. Hyperprolactinaemia should prompt reassessment of the overall treatment strategy, consideration of dose reduction where feasible, or switching to a prolactin-sparing antipsychotic if clinically appropriate.

Similarly, the Royal College of Psychiatrists has repeatedly emphasised that people with severe mental illness experience disproportionate rates of obesity, diabetes, cardiovascular disease, endocrine dysfunction and premature mortality. The College advocates parity of esteem between physical and mental healthcare, requiring psychiatrists to investigate physical illness with the same rigour expected in any other medical specialty.

Persistent hyperprolactinaemia accompanied by type 2 diabetes mellitus, obesity, hypogonadism, osteoporosis or other endocrine abnormalities should therefore trigger consideration of broader endocrine pathology rather than being viewed solely as a medication side effect.

Depot Antipsychotics Create a Higher-Risk Pharmacological Environment

The addition of aripiprazole is particularly complex where the patient remains prescribed depot antipsychotic injections.

Depot preparations cannot be rapidly withdrawn if clinically significant adverse effects develop. Dopamine receptor blockade continues for weeks after administration, substantially reducing therapeutic flexibility.

If adjunctive aripiprazole precipitates akathisia, agitation, insomnia or behavioural deterioration, clinicians cannot immediately remove the underlying pharmacological interaction. Consequently, the threshold for introducing additional dopamine-modulating medication should arguably be higher than in patients treated solely with oral antipsychotics.

Akathisia Is Not a Minor Adverse Effect

Aripiprazole is generally well tolerated, but akathisia remains one of its most clinically significant adverse effects.

Patients frequently describe overwhelming inner restlessness, profound anxiety, inability to remain still, agitation and severe psychological distress. These symptoms can be mistaken for worsening psychosis, anxiety disorders or behavioural disturbance, potentially resulting in further inappropriate prescribing.

The literature has also associated severe untreated akathisia with treatment discontinuation, self-harm and suicidal ideation in some patients.

Where aripiprazole has been prescribed solely to lower prolactin concentrations, the emergence of akathisia fundamentally alters the balance between therapeutic benefit and clinical risk.

Appropriate management should include urgent clinical review, consideration of dose reduction or discontinuation, reassessment of the antipsychotic regimen, symptomatic treatment where indicated, and close follow-up until symptoms resolve.

Multiple Endocrine Abnormalities Should Prompt Endocrinology Referral

The presence of hyperprolactinaemia together with type 2 diabetes mellitus or other endocrine abnormalities should prompt clinicians to ask a broader diagnostic question.

Is the patient experiencing a medication side effect alone, or does the presentation reflect wider endocrine disease requiring specialist investigation?

Potential differential diagnoses include pituitary pathology, hypogonadism, thyroid disease, adrenal disorders, metabolic syndrome and osteoporosis.

Adding aripiprazole may improve one biochemical parameter while delaying diagnosis of another clinically significant disorder.

Referral to a consultant endocrinologist should therefore be strongly considered where endocrine dysfunction extends beyond isolated hyperprolactinaemia, where symptoms remain unexplained, or where long-term complications require specialist assessment.

The Legal Framework: From Bolam to Montgomery

The legal analysis of these prescribing decisions has evolved significantly over recent decades.

Bolam v Friern Hospital Management Committee [1957]

The Bolam principle established that a clinician is not negligent simply because another clinician would have acted differently, provided the decision accords with a responsible body of professional opinion.

Historically, this afforded considerable protection to prescribing decisions supported by accepted clinical practice.

However, modern medical negligence law has moved well beyond Bolam alone.

Bolitho v City and Hackney Health Authority [1998]

The House of Lords refined the Bolam principle by holding that professional opinion itself must withstand logical analysis.

Courts are not obliged to accept expert evidence merely because other clinicians support it. The opinion must demonstrate coherent reasoning and appropriately balance risks against benefits.

In practical terms, this means that merely stating “adjunctive aripiprazole is accepted practice” may be insufficient if inadequate consideration was given to endocrine disease, alternative treatment options, foreseeable adverse effects or the patient’s individual circumstances.

Montgomery v Lanarkshire Health Board [2015]

The Supreme Court fundamentally reshaped informed consent.

Clinicians are now under a legal duty to ensure that patients are informed of:

  • material risks associated with proposed treatment;
  • reasonable alternative treatment options; and
  • the option of declining treatment altogether where appropriate.

A risk is material if a reasonable person in the patient’s position would likely attach significance to it, or if the clinician knows, or should reasonably know that the particular patient would likely consider it significant.

Applied to adjunctive aripiprazole, this means patients should ordinarily be informed about:

  • the off-label nature of treatment;
  • the possibility of akathisia, agitation and insomnia;
  • the possibility that treatment may not adequately resolve symptoms;
  • alternatives such as dose reduction, switching antipsychotics where clinically feasible, observation, or referral for endocrine assessment;
  • the uncertainties associated with adding another psychotropic medicine.

Failure to discuss these matters may expose clinicians to criticism even where prescribing itself was pharmacologically reasonable.

Documentation: The Clinician’s Strongest Defence

In medico-legal practice, contemporaneous documentation frequently determines whether a prescribing decision can be defended.

The medical record should clearly demonstrate:

  • why adjunctive aripiprazole was preferred over alternative strategies;
  • evidence supporting off-label prescribing;
  • informed consent discussions;
  • endocrine and metabolic assessment;
  • monitoring plans;
  • review arrangements;
  • contingency planning should adverse effects emerge.

Documentation should reflect a process of clinical reasoning rather than simply recording a prescribing decision.

Conclusion

Adjunctive aripiprazole remains a legitimate therapeutic option for selected patients with antipsychotic-induced hyperprolactinaemia. However, legitimacy does not eliminate professional responsibility.

Current GMC guidance, NICE recommendations and Royal College of Psychiatrists policy all point towards careful assessment, shared decision-making, systematic physical health monitoring and multidisciplinary management.

The legal authorities of Bolam, Bolitho and Montgomery reinforce these professional duties by requiring that prescribing decisions are supported by logical clinical reasoning, informed by responsible practice, and accompanied by meaningful patient involvement.

Where a patient receiving depot antipsychotic treatment develops persistent hyperprolactinaemia alongside diabetes mellitus or other endocrine abnormalities, the question should not simply be how to suppress prolactin. The more important question is whether the patient requires comprehensive endocrine investigation before additional psychotropic medication is introduced.

In many such cases, early referral to a consultant endocrinologist, combined with a multidisciplinary review of the antipsychotic regimen, is likely to represent the most clinically robust and the most legally defensible course of action.

Polyendocrine Syndromes & Psychiatric Presentation in Patients

May 25, 2026
Uncategorized
Leave a comment

This is why a precision based approach to psychiatry is necessary and not the antiquated and discredited system known as psychogenics, which far more resemble a belief system than any modern scientific evidence based medicine system. 

The psychogenic ‘symptom’ based approach to diagnosis is more a relic of the early 20th century than an evidence based medicine model and in the main health trusts still relying on this are likely lazy and dogmatic and have failed to keep up with neurological research and appropriate training of staff.  Apart from the obvious distress this causes to patients and their loved ones it represents a retrograde attitude to advancing psychiatric and neurological models.  Patents often spend years misdiagnosed and consequently incorrectly treated and more often than not detained in the forensic legal system that also sustains this intellectual bankruptcy in the medical professions. 

The underlying motivation of psychogenic psychiatry is isolation, deprivation of liberty and containment of what is often seem as more of a legal problem than one involving innocent victims of a medical pathology. 

There are several plausible and increasingly studied links between polyendocrine disorders and dysfunctional signaling in the mesolimbic system, particularly involving dopamine, stress hormones, immune signaling, and metabolic hormones. But the relationship is complex and usually indirect rather than a single unified disease mechanism.

The mesolimbic system (especially the VTA → nucleus accumbens dopamine pathway) regulates motivation, reward salience, reinforcement learning, mood, and aspects of energy regulation. Dysregulation in this circuit is implicated in depression, addiction, anhedonia, compulsive behaviours, schizophrenia-spectrum symptoms, and altered motivational states. 

Several endocrine systems feed directly into this circuitry:

1.     Cortisol / HPA axis

2.     Thyroid hormones

3.     Insulin and leptin

4.     Sex steroids

5.     Inflammatory cytokines

6.     Orexin and ghrelin signaling

7.     Prolactin-dopamine feedback loops

So when multiple endocrine systems become dysregulated simultaneously, as in polyendocrine syndromes mesolimbic signaling can adversely be affected.

A few examples of Autoimmune polyendocrine syndromes includes conditions like autoimmune polyendocrine syndrome (APS) often involve chronic inflammation, adrenal dysfunction, thyroid disease, diabetes, or gonadal hormone abnormalities. Cytokines and glucocorticoid instability can alter dopamine neuron firing and reward processing. Chronic inflammatory states are increasingly associated with reduced dopaminergic motivation signaling and anhedonia. 

Thyroid dysfunction.  Hypothyroidism can blunt dopaminergic tone and produce apathy, reduced motivation, depression and cognitive slowing

Hyperthyroidism can produce anxiety, agitation, reward/salience dysregulation and sometimes psychosis-like symptoms

These effects likely involve mesocorticolimbic dopamine modulation. The mesolimbic pathway is highly sensitive to glucocorticoids. Chronic excess cortisol can alter reward salience and stress responsivity, while adrenal insufficiency can impair motivation and emotional regulation. Stress-hormone modulation of VTA dopamine neurons is well established. 

Diabetes and insulin resistance influences. Insulin receptors are expressed in mesolimbic dopamine regions. Impaired insulin signaling can alter reward valuation, food motivation, impulsivity, and dopaminergic transmission. This is one reason metabolic disease and compulsive eating/addiction phenotypes overlap neurobiologically. 

Prolactin and dopamine.  There is a direct endocrine-dopamine loop. Dopamine inhibits prolactin release through D2 receptor signaling. Disorders involving prolactin, pituitary dysfunction, or dopamine blockade can therefore affect motivation, libido, affect, and reward processing. 

There is also an emerging idea that some syndromes that appear “psychiatric,” “metabolic,” and “endocrine” at the same time may involve shared network dysfunction between hypothalamic regulation, immune signaling, salience/reward circuitry and autonomic regulation

That overlap is especially discussed in chronic stress disorders, obesity/metabolic syndrome, inflammatory illnesses, chronic pain syndromes and some neuroimmune conditions


A mesolimbic abnormality would not usually be considered the primary cause of a polyendocrine disorder in mainstream medicine.  More commonly endocrine dysfunction alters mesolimbic signaling, or both are affected by a third process (autoimmune, inflammatory, genetic, developmental, or stress-related).

So the association is biologically credible and supported by growing evidence, but it is not yet a fully unified or clinically standardized framework.

ENHANCED ONGOING SUPERVISION AND THE CODE OF PRACTICE UNDER MENTAL HEALTH ACT 1983

March 17, 2026
Uncategorized
Leave a comment

For all parents and carers affected by barring/heavy ongoing restrictions, this blog is for you. It is regarded as totally unacceptable by the Care Minister (Stephen Kinnock however this is the reality for many in the UK. The ITN programme explored effects on some vulnerable person, parents and carers affected but the sad reality is that this situation is widespread, nationwide with many affected – thousands of vulnerable people are currently incarcerated on MH units for many years, not being properly assessed for physical health/neurological conditions such as FND, epilepsy, denied pathophysiological referrals/tests under neurology, endocrinology and immunology. Others in the community are likewise affected. Following a seizure for instance referral should be made according to Nice Guidelines NG217 within two weeks to see a specialist and there are specific guidelines for delirium. There are families whose vulnerable relative has been sent a long distance away, making visits difficult. It is wrong parents and carers are treated in such a dismissive manner, excluded from care meetings and any involvement by the NHS and certain care homes backed by Local Authorities. For those who complain the ultimate bullying is to deny contact or restrict contact without proper review, often for years on end. This has a widespread, devastating effect on families. On Mother’s Day my thoughts went out to all mothers who have no contact. It is a violation of human rights under Article 8 HRA to the vulnerable person and their families. I hope that something is done about this situation by the Government, especially with regard to neglect towards physical health and denial of pathophysiological tests to that person.

[Mother/Father’s Name]
[Address]
[Postcode]
[Email / Telephone]
[Date]

Clinical Management Team
[Hospital / Trust Name]
[Ward / Unit Name]
[Hospital Address]

Formal Request for Review of 2:1 Supervision and Written Reasons

Dear Clinical Management Team,

Re: 2:1 Supervision During Visits With My Relative (Son/Daughter)

I am writing as the mother of [Patient’s Name] regarding the requirement that two members of staff supervise my visits with my daughter.

While I understand that hospitals must manage risk appropriately, I am concerned that the requirement for two-to-one (2:1) supervision during my visits appears to have been imposed for some time without any clear explanation being provided to me, and without any indication that the restriction has been regularly reviewed.

As you will be aware, decisions affecting detained patients must comply with the Mental Health Act 1983and the guiding principles contained within the Mental Health Act Code of Practice.

The Code of Practice provides that:

·       Paragraphs 1.2 and 1.8 require that patients should only be subject to restrictions that are necessary and proportionate, and that the least restrictive option must be considered.

·       Paragraph 1.5 requires that any restrictive intervention must have a clear purpose and must not be imposed simply as a matter of routine.

·       Paragraph 1.7 emphasises the importance of respect, dignity and maintaining relationships with family members.

In addition, the continued imposition of 2:1 supervision during family visits interferes with the patient’s right to family life under Article 8 of the European Convention on Human Rights, which forms part of UK law through the Human Rights Act 1998. Any such interference must therefore be necessary, proportionate and capable of clear justification.

The presence of two staff members during visits makes it extremely difficult for my son/daughter and I to have normal private conversations and significantly affects our ability to maintain a meaningful family relationship.

If this restriction has not been regularly reviewed against current risk, it raises a concern that the requirement may be operating as a routine or blanket restriction, rather than a proportionate response to an identified risk.

Accordingly, I would be grateful if you could please provide the following information:

1.     The clinical rationale for imposing 2:1 supervision specifically during my visits.

2.     The dates and outcomes of all reviews of this restriction since it was first introduced.

3.     The risk assessment(s) currently relied upon to justify maintaining this level of supervision.

4.     Whether less restrictive arrangements for family visits have been considered.

5.     The date when this restriction will next be formally reviewed.

If this requirement has not been subject to regular and documented review, I am concerned that the continued imposition of 2:1 supervision during my visits may be disproportionate and therefore potentially unlawful.

For the avoidance of doubt, this letter should be treated as a formal request for written reasons for the restriction currently being imposed, and I would be grateful for a written response within 14 days.

If it would assist, I would also be happy to discuss the matter with the clinical team so that an arrangement can be agreed which appropriately balances safety with my son/daughter’s right to maintain a normal family relationship.

Yours sincerely,

[Mother’s Name]

HERE ARE THE GUIDELINES AND THOSE REGARDING SEIZURES AND DELIRIUM FOR ANYONE AFFECTED

NICE Guideline NG10 – Violence and Aggression: Short-Term Management in Mental Health Settings, and NHS Trust Enhanced Observation Policies.

Risk assessments must be regularly reviewed

The guideline requires continuous review of risk management plans:

Risk assessments and risk management plans should be regularly reviewed, and care plans must be based on accurate and thorough risk assessments.

This principle directly affects enhanced observation levels such as:

· 1:1 observation

· 2:1 observation

· constant observation

If the observation level is not being reviewed regularly, it may breach national clinical guidance.

How NG10 Connects to 2:1 Supervision

Although NG10 does not specify the exact term “2:1 supervision”, it governs the restrictive interventions and observation frameworks that hospitals rely on when implementing such measures.

Typical NHS observation levels include:

Observation level Description

General

observation periodic checks

Intermittent

observation checks at set intervals

Within eyesight continuous observation

Within arm’s

length very high-risk monitoring

2:1 observation two staff members observing the patient

Under NICE and NHS policy:

· the clinical justification must be documented

· the observation must be reviewed frequently

· it must remain proportionate and justified by evidence

PRE-ACTION PROTOCOL LETTER TO FOLLOW UP IF NO RESPONSE

[Your Name] [Your Address] [Postcode] [Email / Telephone]

Date: [Insert Date]

BY EMAIL AND RECORDED DELIVERY

The Responsible Clinician The Ward Manager The Mental Health Act Office [Name of NHS Trust] [Hospital Address]

LETTER BEFORE ACTION – INTENDED COURT OF PROTECTION PROCEEDINGS

Re: [Patient’s Full Name / DOB] – Unlawful Contact Restrictions and 2:1 Supervision

Dear Sir/Madam,

I write formally concerning the ongoing restrictions placed upon my contact with [Patient’s Name], who is currently receiving care at [Ward/Hospital] under the responsibility of [NHS Trust].

This letter constitutes a formal Letter Before Action and should be treated as notice that, unless the matters set out below are addressed urgently, I intend to issue proceedings in the Court of Protection without further notice.

Unlawful Interference With Family Life

The Trust is currently restricting or controlling my contact with [Patient’s Name], apparently on the basis of the patient’s 2:1 supervision / enhanced observation level.

These restrictions amount to a serious interference with family life, protected under the Human Rights Act 1998 – Article 8 (Right to respect for family life)

Any interference with Article 8 rights must be lawful, necessary, proportionate and supported by evidence of risk

At present, the Trust has failed to demonstrate that these requirements are satisfied.

Statutory Duties Under the Mental Capacity Act

If the patient lacks capacity to determine contact arrangements, the Trust is under a statutory duty to act in accordance with the Mental Capacity Act 2005.

In particular:

· Section 4 requires all decisions to be taken in the person’s best interests, including proper consideration of family relationships.

· Sections 15 and 16 confer jurisdiction on the Court of Protection to determine issues relating to welfare, contact, and care arrangements.

Where contact between a patient and family member is restricted without lawful justification, the Court may make binding welfare orders regulating contact and directing the NHS Trust to amend its care arrangements.

Observation Policies and 2:1 Supervision

The Trust appears to be relying on the patient’s 2:1 supervision level as justification for the present restrictions.

Enhanced observation measures of this type are governed by NICE Guideline NG10 – Violence and Aggression: Short-Term Management in Mental Health Settings, and NHS Trust Enhanced Observation Policies.

These policies require that:

· Enhanced observations must be risk-based and individually justified

· Observation levels must be subject to regular clinical review

· The least restrictive principle must be applied

· Restrictions on family contact must be supported by a specific risk assessment relating to that contact

Enhanced observation does not provide lawful authority for blanket restrictions on family contact.

Serious Procedural Concerns

Despite repeated requests, the Trust has failed to provide:

· the risk assessment said to justify restricting family contact

· the care plan provisions governing such restrictions

· observation review records relating to the patient’s 2:1 supervision

· any evidence demonstrating that less restrictive alternatives have been considered

If these documents do not exist, the current restrictions may be unlawful and incompatible with both the Mental Capacity Act and Article 8 rights.

Required Disclosure

In order to avoid litigation, the Trust is requested to provide the following within 14 days:

1. The patient’s current care plan.

2. All risk assessments relating to family contact.

3. All observation level review records relating to the patient’s 2:1 supervision.

4. The policy or clinical basis relied upon to restrict family contact.

5. Confirmation of the schedule and procedure for reviewing observation levels and associated restrictions.

Intended Court of Protection Application

If the above information is not provided, or if the current restrictions remain in place without lawful justification, I will issue proceedings in the Court of Protection seeking:

· A declaration regarding the patient’s capacity to decide contact

· A declaration that the current restrictions are unlawful and disproportionate

· A welfare order regulating contact between the patient and family members

· Directions requiring the Trust to amend the care plan and observation arrangements

· Any further relief the Court considers appropriate

The Court of Protection has the power to make binding orders requiring NHS Trusts to alter care arrangements where they unlawfully interfere with family life.

Opportunity to Resolve Without Litigation

Litigation can still be avoided if the Trust:

· reviews the current restrictions urgently,

· provides the documentation requested above, and

· confirms that the patient’s contact with family will be managed in accordance with statutory duties and the least restrictive principle.

If no satisfactory response is received within 14 days, proceedings will be commenced without further notice.

Yours faithfully,

[Your Name]

NICE NG217 Guideline on Seizures

1. Urgent referral after first seizure or recurrence

NG217 1.1.1 – First suspected seizure

“Refer children, young people and adults urgently (for an appointment within 2 weeks) for an assessment after a first suspected seizure”
— NICE NG217¹, Recommendation 1.1.1. 

This uses urgent referral, defined by NICE as an appointment within 2 weeks, for anyone after a suspected seizure.

NG217 1.1.2 – Seizure recurrence

“Refer children, young people and adults urgently (for an appointment within 2 weeks) for an assessment if they have a seizure recurrence after a period of remission.”
— NICE NG217¹, Recommendation 1.1.2. 

A recurrence after remission is repeated and unexplained, and under NICE this is explicitly urgent — same timeframe as first seizure.

2. Implication for repeated unexplained seizures

Even though NG217 does not use those exact words (“repeated unexplained seizures”) in a standalone recommendation, the guidance is clear from these linked recommendations:

  • Any recurrence (repeated seizure) after a seizure-free period triggers the same urgent referral timing as a first seizure.
    → This means 2 weeks maximum to specialist assessment. 
  • The guideline does not recommend routine or non-urgent pathways for recurrent or potentially multiple unexplained seizures in adults or children. 

3. Investigations are recommended promptly too

While NG217 separates referral timing (urgent within 2 weeks) from investigations, it also states:

EEG timing

“…if an EEG is requested after a first seizure, perform it as soon as possible (ideally within 72 hours after the seizure).”
— NICE NG217, EEG section. 

This supports early investigation following urgent specialist review.

Neuroimaging

“Offer brain neuroimaging tests if an underlying structural cause is suspected…”
— NICE NG217. 

This reinforces that after urgent specialist assessment, relevant investigations should not be unreasonably delayed when clinically indicated.

SituationNICE RecommendationTimeframe
First suspected seizureUrgent specialist referral (1.1.1)Within 2 weeks
Repeat seizure after remission (i.e., repeated unexplained)Urgent specialist referral (1.1.2)Within 2 weeks
EEG after suspected seizureEarly investigationIdeally within 72 hrs
Neuroimaging if neededPrompt test as indicatedNo specified fixed max—but not deferred

Key takeaway from NICE wording

NICE NG217 does not permit prolonged routine delays for repeated unexplained seizures. According to its urgent referral recommendations (1.1.1 & 1.1.2):

A recurrence or repeated unexplained seizure merits the same urgent (2-week) referral as a first seizure. 

Follow-up investigations (EEG, imaging) should then be arranged as soon as clinically appropriate, not deferred indefinitely. 

NICE GUIDELINES  CG103  DELIRIUM

Before the referral meeting and most certainly before the scan a patient needs to be properly rested to avoid physiological confounders.  

Good clinical practice in cognitive and neurological assessment requires that potentially reversible causes of impaired cognition are identified and corrected before diagnostic conclusions are drawn.

Under NICE guideline CG103 (Delirium: prevention, diagnosis and management), clinicians must assess for acute physiological contributors to confusion, including dehydration, infection, hypoxia, hypoglycaemia, metabolic disturbance, and medication effects. The guideline emphasises that delirium is common, serious, and frequently reversible, and that failure to detect underlying medical causes risks misdiagnosis.

Accordingly, cognitive assessment should occur only when the patient is medically stable. Good practice therefore includes:

  • Excluding delirium and acute illness
  • Correcting dehydration and metabolic abnormalities. (nourishment, breakfast to avoid hypoglycaemia)
  • Reviewing medications and substances
  • Managing pain and sleep disturbance (a proper nights sleep before to avoid confusion due to tiredness) 
  • Ensuring appropriate sensory aids and a suitable testing environment

While CG103 does not explicitly state that a patient must be “relaxed and properly nourished,” its requirements to identify and treat reversible contributors to confusion implicitly support optimisation of physiological and environmental conditions prior to assessment.

In summary, consistent with CG103, cognitive evaluation should be undertaken under conditions that minimise reversible confounders to ensure diagnostic validity and patient safety.

COUNCIL & TRUST FAILINGS IN: Care planning, Continuity /Consistency of Care, Capacity in Recovery Services, and Responsiveness to Changing Needs.

November 17, 2025
Uncategorized
Leave a comment

Evidence of New / Escalating Criticism of Lincolnshire Adult Social Care

Ombudsman / Care Act Failures

A recent (April 2025) LGO decision (ref 24-003-962) found fault in how LCC (via Lincolnshire Partnership NHS Trust, acting for LCC) handled a Care Act assessment and care plan for a person with mental and physical health needs. Specifically: no advocate was involved despite communication difficulties, care was inconsistent, and there was poor communication / information-sharing — this caused distress. Local Government Ombudsman

Another case (Centre for Adults’ Social Care report, June 2025) describes a woman with complex mental health needs whose move into the county triggered fragmented / inadequate support. LCC (via its partner trust) failed to provide consistent care, arranging too few hours vs her assessed need, and she suffered distress, hospital admissions, and isolation. cascaidr.org.uk

A separate Ombudsman ruling (July 2025) relates to transition from children’s to adult services. LCC made “errors in care package decisions and communications” for a young adult with disabilities (including transport for day-centre attendance), causing her to miss care. cascaidr.org.uk+1

Healthwatch Lincolnshire Feedback

The Healthwatch Lincolnshire report (2025) includes a case (Feb 2025) of an adult social care user whose health needs were compromised because of lack of proper care provision. According to the report, the person is a wheelchair user and needs increased care post-operation, but LCC could not guarantee provision for that increased care, leading to the cancellation of a surgery. Healthwatch Data

While this is not explicitly “mental health care,” it shows stress / risk in how adult social care assesses and responds to changing care-need demands — including when health interventions (surgery) would make care needs temporarily more intense.

Local Media / Policy

Lincolnshire World reported very recently (Oct 2025) that LCC officials are considering reducing the number of “active recovery beds” (mental-health-related step-down beds) from 29 to 24. That’s a significant signal: reducing capacity in part of the mental health recovery system could be seen as cutting back or deprioritising mental health care for adults. LincolnshireWorld

Complaint Statistics

In its 2024–2025 complaints report, LCC notes that 23 complaints from that year were escalated to the LGSCO about adult care. Lincolnshire County Council

While not all these will be about mental health, it suggests a non-trivial volume of serious complaints in the adult care sphere.

Interpretation & Assessment

The Ombudsman findings are the strongest concrete evidence: there are real cases where LCC has failed to provide or plan care properly for people with mental health or complex needs. These are not isolated paperwork mistakes, they have caused distress and had a material negative impact.

The Healthwatch case indicates that some people struggle to get social care to respond when their health needs (which may interact with mental health) change. That could suggest capacity / resource problems in LCC’s adult social care provision.

The proposal to reduce active recovery beds is worrying: if implemented, it could worsen recovery pathways for people needing step-down mental health care. That could be a policy direction that reduces service rather than expands it.

However, the CQC’s most recent (pilot) assessment of LCC adult social care is still “Good”, which means from a regulator’s perspective, the overall adult social care system is functioning reasonably well (though not without room for improvement, especially in certain pathways). Lincolnshire County Council+2Care Quality Commission+2

There is new and escalating criticism of LCC’s mental-health-related adult care: through Ombudsman decisions, Healthwatch reports, and potentially in policy (bed reductions).

The criticisms are not wholesale systemic collapse, but they do raise serious concerns about how well LCC is meeting the needs of vulnerable adults — particularly those with complex mental health or changing care needs.

Some of the key pressure points: assessment and care planning, continuity / consistency of care, capacity in recovery services, and responsiveness to changing needs.

Briefing Summary: Criticisms of LCC Adult Mental Health Care (2023–2025)

1. Financial & Demand Pressures

LCC’s 2024/25 financial performance review reports a significant overspend in mental health adult care:

Community supported living (for working-age / mental health clients) overspent by £3.2 million, of which £1,060,000 relates to “Growth in demand for DoLS / LPS” (Liberty Protection Safeguards) due to a much higher-than-expected increase in client numbers (94 new clients vs 25) planned). lincolnshire.moderngov.co.uk+2lincolnshire.moderngov.co.uk+2

Long-term residential mental health care also saw growth: 27 new clients, resulting in a £0.408 million overspend. lincolnshire.moderngov.co.uk+1

Short-term care (mental health) clients exceeded budgeted numbers, adding further financial pressure. lincolnshire.moderngov.co.uk+1

The budget for 2025/26 continues to forecast rising demand in mental health: LCC recognizes a 3–6% annual growth in working-age / mental health service demand. lincolnshire.moderngov.co.uk

In its executive meeting (Aug 2025), the Overview & Scrutiny Management Board flagged this as a “volatile and risk-based” budget area, with ongoing close monitoring. lincolnshire.moderngov.co.uk

Implication: LCC may be under-estimating both the scale and pace of demand growth for mental health care, risking repeated overspends and service strain.

2. Service Reduction Controversies – Active Recovery Beds

Local media (LincolnshireWorld) report that LCC is proposing to reduce the number of Active Recovery Beds (ARBs) from 29 to 24. LincolnshireWorld

These beds are used for people stepping down from hospital but not yet ready to return home, reducing them could limit “step-down” capacity. LincsOnline+1

The Council argues the reduction aligns with “presenting demand” and will improve occupancy (from ~70% to ~90%). LincolnshireWorld

However, some councillors have expressed concern: e.g., whether this reduction under-provides in the face of broader NHS / social care pressures. LincolnshireWorld+1

Implication: The proposed cut could undermine recovery capacity; critics worry demand may outstrip reduced supply, especially as patients leave hospital.

Ombudsman Findings – Assessment & Care Planning Failures

In LGO decision 24-003-962 (April 2025), the Ombudsman upheld a complaint against LCC:

LCC (via its partner, Lincolnshire Partnership NHS Trust) failed to provide reasonable adjustments in a Care Act assessment despite the complainant’s mental and physical health issues. Local Government Ombudsman

The decision-making was inconsistent: carers were not familiar with her, there was inadequate handover, and no advocate was involved even when needed. Local Government Ombudsman

The Council also made housing decisions (moving the person) that the Ombudsman found unsuitable. Local Government Ombudsman As a remedy: LCC must apologise and pay a sum to acknowledge the injustice caused. Local Government Ombudsman

A separate Cascaidr analysis (July 2025) highlights another case: LCC failed to properly manage a care package for a person with mental health and possibly autistic traits. Adult Social Care Centre

The complaint noted that LCC did not properly assess the person’s capacity or share information with providers, leaving her without adequate support. Adult Social Care Centre

The analysis argues that LCC’s assessment systems / legal understanding may be weak in dealing with complex, capacity-fluctuating mental health cases. Adult Social Care Centre

Another Cascaidr / Ombudsman case (Sept 2025): poor management of transition from children’s to adult services for a young woman with disabilities (including mental health / supportive needs). Adult Social Care Centre

The Council initially promised transport + day-centre attendance but later withdrew transport without confirming that a closer centre could meet her needs, resulting in missed care. Adult Social Care Centre

The Ombudsman found LCC at fault: decisions were made without fully checking alternatives; communication was confusing; and there was procedural failure in its authorisation processes. Adult Social Care Centre

The Council was required to apologise and pay a symbolic amount, and to remind staff about proper internal authorisation procedures. Adult Social Care Centre

Implication: There appear to be systemic weaknesses in LCC’s assessment, planning, and communication processes especially for people with complex mental health needs or transitioning from children’s services. This raises risk of unmet need, distress, and legal non-compliance.

Local Advocacy / Healthwatch Voice

Healthwatch Lincolnshire’s 2024/25 Annual Report shows increasing engagement, but also highlights challenges: while not all issues are mental health–specific, many concern social care access, capacity, and unmet needs. healthwatchlincolnshire.co.uk

In the 2024–25 interim work plan, Healthwatch identified “influencing decision-makers” and “addressing underrepresented groups” as key priorities, suggesting they are pushing for more responsive, inclusive care provision. healthwatchlincolnshire.co.uk

Local media commentary (LincolnshireWorld) also notes LCC acknowledging rising complexity in mental health care packages and growing costs:

“a major contributor to cost pressures … an increase in demand and complexity of mental health services.” LincolnshireWorld

Implication: Local citizen-led organisations are raising the alarm about escalating demand, growing complexity, and pressures on mental health adult care — suggesting these are not just financial issues but affect quality and accessibility.

Strategic & Systemic Risks

During a Council Executive meeting (July 2025), a councillor (Steve Clegg) explicitly questioned LCC’s mental health community support overspend. The Executive Director (Adult Care) acknowledged demand is rising “faster than elsewhere” and hinted at concerns over the quality of existing service delivery. Open Council Network

LCC’s written evidence to Parliament (recent submission) also warns that demand for adult mental health care is exceeding previous forecasts, putting “increasingly strained” pressure on the system. UK Parliament Committees

Implication: The financial and service pressures are not short-term or one-off: there’s a real risk that demand continues to outpace LCC’s capacity, potentially degrading care quality or forcing tough decisions (like bed cuts).

Overall Summary

Demand is rising fast: LCC is seeing more working-age / mental health adult clients than budgeted for, driving large cost overruns.

Service capacity is under threat: Proposed reductions in Active Recovery Beds raise concerns about recovery pathways.

Professional standards are being questioned: Ombudsman decisions show LCC sometimes fails in assessments, support planning, and legal duties, especially for those with complex, fluctuating mental health needs.

Local voices (Healthwatch, Councillors) are pushing back: There is growing unease about how LCC is managing this demand, both financially and in terms of service delivery.

Strategic risk is real: Unless LCC adapts, by increasing capacity, improving assessment processes, and planning strategically — there is a danger that its mental health adult care provision will become unsustainable.

A separate Cascaidr analysis (July 2025) highlights another case: LCC failed to properly manage a care package for a person with mental health and possibly autistic traits. Adult Social Care Centre

The complaint noted that LCC did not properly assess the person’s capacity or share information with providers, leaving her without adequate support. Adult Social Care Centre

The analysis argues that LCC’s assessment systems / legal understanding may be weak in dealing with complex, capacity‑fluctuating mental health cases. Adult Social Care Centre

The Care Act 2014 requires councils to assess any adult who appears to need care and support, regardless of financial circumstances, and to involve the individual and any carer or anyone else they wish to be involved. Assessments must be timely, involve the person, and consider their wellbeing and desired outcomes. Care and support plans must be co-produced, include a personal budget, and be responsive to changing needs. 

When a person moves between council areas, there are statutory duties to ensure continuity of care (section 37), but they do depend on the destination council knowing that the person is on their way. 

Councils must also consider reasonable adjustments for communication and mental health needs, and ensure advocacy is provided where it is triggered by the concept of the person’s substantial difficulty engaging in the Care Act processes of assessment, care planning or revision (regardless of having a willing relative) without one being appointed. 

The failure to provide adequate care and support, or to arrange advocacy, is a breach of statutory duty.  It renders the assessment invalid, in community care and public law and that has been the case since the Haringey judgment in 2015.

Locked In: How the Mental Capacity Act is Failing the Vulnerable

November 17, 2025
Uncategorized
Leave a comment

Every year, tens of thousands of vulnerable adults, elderly people with dementia, individuals with learning disabilities, psychiatric patients are subject to care decisions under the UK’s Mental Capacity Act 2005 (MCA). The Act was designed as a safeguard: to ensure their rights, to assess whether they can make decisions, and to limit the use of coercion. But a growing body of evidence suggests that many Local Authorities and NHS trusts are failing at that mission. Rather than protecting autonomy, systems designed to shield people from abuse may be enabling institutional convenience.

A System Under Pressure

According to the Care Quality Commission (CQC), the system overseeing deprivation of liberty is creaking. Their 2023–24 report on DoLS (Deprivation of Liberty Safeguards) found that many supervisory bodies are “significantly under-resourced.” Some local authorities told CQC they lack enough assessors and cannot keep pace with soaring demand. Care Quality Commission

One local authority said they would “be doing this for around 18 months just to clear” their backlog if no new applications came in. Care Quality Commission

The problem: only 19 % of DoLS applications are completed within the legal limit of 21 days; many people wait between 12–18 months. Local Government Lawyer+2Care Quality Commission+2

Resource-constrained councils cite staffing shortages and rising caseloads as the key drivers. Local Government Lawyer

This is not a quirk – it’s systemic. SCIE (the Social Care Institute for Excellence) analysis shows 67% of local authorities assessed by the CQC still “require improvement” in their DoLS arrangements. Local Government Lawyer

When Safeguards Are Delayed, Rights Are Denied

The delays are not harmless. In some cases, people who should have formal protections under the MCA are left in legal limbo. The Local Government & Social Care Ombudsman (LGSCO) has repeatedly raised red flags:

In a high-profile case, Surrey County Council had 5,700 outstanding DoLS requests as of 31 March 2022. Bond Solon

The average time to complete an assessment in that area was 345 days, more than double the national average of 154 days. Bond Solon

The Ombudsman found that Surrey appeared to rely on an “ADASS screening tool” to prioritise, but in so doing, “were not following the legal criteria contained in the Mental Capacity Act … around time frames.” Bond Solon

In another case, Southampton City Council was criticized for its high numbers of outstanding MCA assessments and DoLS applications (382 and 404 respectively), and for delaying assessments so long that people were restricted without the legal protections they ought to have. Local Government Lawyer

Misunderstanding, Misapplication, and Mis-training

Many of the problems stem not only from resource scarcity, but from widespread misunderstanding of the MCA among professionals:

Poor Understanding by Providers

In its 2022–23 monitoring report, CQC found that some providers did not properly implement the conditions of DoLS authorisations (e.g., access to places of worship or visits), meaning the restrictions imposed might not actually reflect the person’s best interests. Care Quality Commission There was also “poor recording of mental capacity assessments.” Care Quality Commission

In some mental health settings, CQC observed that staff did not clearly understand the interface between the MCA and the Mental Health Act, leading to poor decisions about which framework to use. Care Quality Commission

Lack of Training & Governance

According to a CQC report from 2013, care staff often misunderstood even the basics of the MCA, restraint was not always recorded or considered properly, and “best interests” decisions were sometimes poorly documented. Care Quality Commission

The same report noted that, in some services, there was little attempt to maximise a person’s capacity before resorting to restrictions. Care Quality Commission

Mental Capacity Law and Policy (a specialist commentary) analysed 139 “Notices of Proposal” from 2023–24 (when new providers were registering) and found that 66 related explicitly to noncompliance with the MCA. Mental Capacity Law and Policy

Institutional Incentives Over Individuals’ Best Interests

Beyond lack of training, some systemic incentives risk tilting decisions in favour of institutions rather than individuals:

The Social Care Institute for Excellence (SCIE) argues that resource pressures are pushing councils toward “triage approaches”: using screening tools to prioritise some cases, leaving others in backlog indefinitely. Local Government Lawyer

CQC’s State of Care report observed a “wide variation” in how different local authorities manage applications, with some applying blanket restrictions to all residents, even when less restrictive options might suffice—raising the question of whether these measures are more about institutional convenience than individual rights. Community Care

In its analysis, CQC also noted a “misconception among some providers that a DoLS application equated to an authorisation being in place.” In other words, some staff may believe applying for DoLS is enough, without fully thinking through what restraints should or should not be authorised. Community Care

Consequences for People

The human cost is considerable. The Health & Care Professionals Alliance (HCPA) published a report, The Right to Decide, collating investigations by the Ombudsman:

One person was removed from their family home in the dead of night without prior notice, without formal capacity assessments. HCPA

Another was moved 15 miles away to a care home, but no adequate best-interests process had been documented; friends and family felt cut out of decision-making. HCPA

In a third case, the complaint upheld by the Ombudsman noted that organizations had failed to collaborate and ensure the person received the care they actually needed, rather than what was convenient. HCPA

Over one year (2016–17), the Ombudsman estimated that up to 20% of adult social care complaints they investigated concerned capacity or DoLS; 69% of those cases were upheld, indicating systemic failure. HCPA

Judicial and Legal Alarm Bells

Legal scrutiny has also exposed deeper problems in how capacity assessments are carried out:

A recent Mental Capacity Report (March 2025) highlighted how local authority assessments sometimes rely on “unstructured” or flawed capacity-assessment forms that fail to align with the statutory framework of the MCA. Judges have pointed out the need for assessments to be “evidence-based, person-centred … not made to depend … upon the identification of a so-called unwise outcome.” Mental Capacity Law and Policy

The report also emphasizes the mental/clinical versus legal distinction: “insight is a clinical concept, whereas decision-making capacity is a legal concept.” When that line is blurred, local authorities risk wrongly judging people to lack capacity. Mental Capacity Law and Policy

Reform on the Horizon – But Progress Is Slow

The system’s flaws are well known, and reform has been promised for years. The Law Commission criticized the existing DoLS framework as a “bureaucratic nightmare” back in 2017, estimating that thousands were being held without proper authorisation. The Guardian Reform is due via the Liberty Protection Safeguards (LPS), but even the transition has collided with delays, confusion, resource constraints, and lack of clarity among commissioning bodies. Care Quality Commission+1

Why This Looks Like “Misuse”

All this is not necessarily sinister. It may not always be malicious. But the patterns suggest that institutional pressure (caseload, funding) is influencing how the MCA is applied.

“Backlogs” are used to justify delayed or reduced protections, potentially depriving people of their legal rights.

Poor understanding of the law among providers and assessors means that deprivation of liberty sometimes happens without rigorous, lawful assessment.

Some providers treat DoLS applications as a “box tick” rather than a serious, rights-based safeguard.

There is little consistency in how authorities prioritise or justify cases, raising questions about equity and accountability.

In short: the system designed to protect autonomy may be bending to convenience.

Voices of Concern

Advocacy groups and legal commentators argue that the very architecture of DoLS makes it vulnerable to misuse.

Families bereft of influence after capacity decisions feel marginalised.

The CQC has repeatedly warned of human rights risks, urging “urgent reform” to ensure people do not remain indefinitely in restrictive settings without proper legal safeguards. Community Care

What Needs to Change

From the evidence, three priorities emerge:

Local authorities desperately need more staff trained in MCA assessments, best-interests decision-making, and authorising deprivations of liberty.

Providers must deepen their understanding of not just how to assess capacity, but why; training must embed respect for autonomy, not just risk management.

There should be clearer mechanisms to hold councils and trusts accountable when they fail or delay assessments, including robust advocacy for individuals and families, and accessible appeals.

The Mental Capacity Act 2005 was meant to be a guardian of dignity, choice and protection. But in too many cases, it is being stretched—by overwork, underfunding, misunderstanding, and institutional inertia—into something else: a tool that limits liberty under the guise of safeguarding. The neglect may not always be malicious, but the effect is often the same: vulnerable people left waiting, unheard, and powerless.

Unless reform accelerates, the very safeguards meant to protect them may end up being the prison.

Locked In: How the Mental Capacity Act Is Being Bent

A 2023–25 Court of Protection Timeline

Since 2023, a steady stream of Court of Protection and family-court judgments, regulator reports and ombudsman decisions have drawn a picture of a system stretched to breaking. Chronic DoLS (Deprivation of Liberty Safeguards) backlogs, inconsistent legal reasoning about when someone is “deprived of liberty”, and repeated judicial reminders that local authorities and NHS bodies must follow the statutory safeguards.

The evidence does not usually show conspiratorial intent; it shows routine institutional pressure (backlogs, triage, lack of expertise) producing unlawful or inadequate use of the Mental Capacity Act 2005 (MCA). Below I trace the most important court decisions and official findings from 2023–2025 that illustrate how those failures translate into people losing rights and legal protections.

Quick summary of the headline evidence (short)

DoLS backlogs and missed statutory timeframes have been documented by the CQC and Ministry of Justice statistics, leaving many people without timely authorisations. Care Quality Commission+1

The Local Government & Social Care Ombudsman (LGSCO) has upheld complaints where councils failed to assess DoLS requests within legal timeframes, finding people “wrongfully deprived” or left restricted without proper authorisation. Local Government Lawyer+1

Court of Protection judgments in 2023–2025 illustrate recurrent themes: disputes about whether an intervention amounts to a deprivation of liberty, whether the Mental Health Act or MCA should apply, and whether authorisations or court orders were achieved lawfully and with proper best-interests reasoning. Mental Health Law Online+2Court of Protection Hub+2

Timeline: key court decisions, regulator findings and turning points (2023–2025)

2023 Rising Court workloads; judicial scrutiny of care plans

Jan–Jun 2023 Lancashire & South Cumbria NHS Foundation Trust v AH [2023] EWCOP 1

HHJ Burrows considered whether a proposed placement and care regime for AH involved a deprivation of liberty, and emphasised the need for careful, evidence-based assessment of whether restrictions go beyond what is necessary and lawful; the judgment shows how complex clinical/risk decisions become legal disputes requiring judicial oversight when the boundaries between care and confinement are blurred. Mental Health Law Online

May 2023, Manchester University Hospitals NHS Foundation Trust & JS [2023] EWCOP 12 A judgment explored the expiry of a Mental Health Act authority and the resulting question whether a person then lacked lawful authorisation and therefore was being deprived of liberty under the MCA. The case emphasises the fragile interface between the Mental Health Act and the MCA and how administrative lapses can convert clinical placements into unlawful deprivations. Court of Protection Hub

Mid-2023, Surge in Court of Protection workload and DoLS applications Commentators and the National Deprivation of Liberty Court reported rising numbers of applications — Courts were seeing more DoL applications and challenges, creating delay and pressure on judicial lists. These workload pressures mirror the operational backlogs being reported by authorities. Community Care+1

2024. Backlogs, legal uncertainty and children’s cases

Early–Mid 2024. Court decisions emphasise rigor of capacity reasoning Judges continued to insist capacity and best-interests assessments be person-centred and evidence-based; some hearings were listed (or refused on paper authorisation) because the court would not rubber-stamp restrictions in the absence of robust reasoning. The “failed to authorise on the papers” approach demonstrates judicial unwillingness to accept weak or incomplete local authority evidence. openjusticecourtofprotection.org

Mid–2024. Record Court activity and a spike in challenges. Ministry of Justice and reporting bodies recorded sharp rises in DoL/Court of Protection activity (for example, large increases in challenges and applications in early-2024), feeding a public debate that some deprivation orders are being used as a cheaper, quicker option than community care packages. Campaigners argued the rise signalled an institutional shift towards authorising restrictions rather than funding viable community alternatives. The Guardian+1

2024 Children’s deprivation-of-liberty jurisprudence. The family and High Court continued to revisit whether parental/local-authority consent can lawfully authorise confinement of children (cases flowing from Lincolnshire CC v TGA (2022) and related 2024 hearings). These decisions underscore how confusion about who can legally “consent” to restrictions risks inappropriate or unreviewed confinements for young people. (The Court of Appeal would then revisit these issues in 2025.) 39 Essex Chambers+1

2025 Consolidation, pushback and appellate refinement

Jan–Apr 2025. Continued judicial clarification (Re V (Profound Disabilities) and related High Court judgments)

High Court judgments in 2025 examined the fine line between care that meets profound needs and state action amounting to deprivation of liberty, finding in some instances that severe disability (and incapacity to leave) meant there was no Article 5 deprivation because the person could not, physically, assert liberty in the ordinary sense. These nuanced rulings highlight inconsistency in outcomes across jurisdictions and how factual differences produce different legal results, which in turn creates inconsistent practice by local authorities. Mental Health Law Online+1

2024–2025. Ongoing CQC warnings and statistical picture CQC’s State of Care reporting for 2023–24 documented that only 19% of standard DoLS applications were processed within the statutory 21-day window and that over 120,000 people were awaiting authorisation at March 2024, a scale of backlog that the regulator described as a human-rights risk. The chronic backlogs and the use of risk-based triage were repeatedly flagged as drivers of unlawful or delayed authorisations. Care Quality Commission+1

April 2025. Court of Appeal revisits limits on local authority consent for children (J v Bath & NE Somerset Council & Ors [2025] EWCA Civ 478). The Court of Appeal corrected earlier Family Division reasoning and clarified that local authorities cannot simply “consent” to confinement for children in their care in the same way parents can, a ruling that tightened a prior area of legal uncertainty and reduced scope for local authorities to rely on loose consent arguments. This is an example of appellate courts pushing back where local practice had expanded the boundaries of lawful restriction. Mental Capacity Law and Policy

Representative examples where court/regulator findings show misuse (or unlawful application) of the MCA

Administrative or procedural failures that created unlawful deprivations. The Manchester University Hospitals case shows how expiry of an appropriate authorising power can leave a person without lawful authorisation; judges have been alert to gaps where no lawful regime was in place but the person remained restricted. Court of Protection Hub

Prioritisation/triage and backlog decisions producing restrictive outcomes without timely authorisation. CQC statistics and Ombudsman decisions (e.g., Surrey County Council LGSCO findings) document councils using screening tools and prioritisation, resulting in very long waits for DoLS assessments and people effectively restricted without legal protections. Care Quality Commission+1

Confusion at the MHA–MCA interface and inappropriate use of one regime to avoid another. Judgments have repeatedly had to untangle whether the Mental Health Act or the MCA should apply; errors or delays in determining the correct legal framework have led to contested deprivations of liberty that end up in court. Court of Protection Hub+1

Use of the inherent jurisdiction/family court in place of clearer statutory routes. In children’s cases, family courts’ use of parental consent or inherent jurisdiction to authorise confinement has provoked appellate correction (2024–25) because the practice risked leaving children without the specific statutory safeguards intended by the DoLS/LPS frameworks. 39 Essex Chambers+1

What the cases show about why misuse (or inadequate use) happens

Pulling the cases and reports together shows repeated causal drivers:

Capacity and DoLS workloads are outpacing resources. Authorities adopt risk-based triage and screening tools (documented by CQC and LGSCO). Care Quality Commission+1

Knowledge gaps and weak record-keeping. Courts regularly call for evidence-based, person-centred capacity assessments and find records are often inadequate. Mental Capacity Law and Policy

Legal uncertainty (children, the MHA–MCA interface, what constitutes “state responsibility”) leads to inconsistent practice; judges correct the approach but only after rights have been restricted. 39 Essex Chambers+1

Case snapshots (short, cited extracts you can follow up)

Lancashire & South Cumbria NHS Foundation Trust & Lancashire CC & AH [2023] EWCOP 1. HHJ Burrows authorises measures but stresses careful scrutiny of deprivation questions. (See mentalhealthlaw and Court of Protection Hub summaries.) Mental Health Law Online+1

Manchester University Hospitals NHS Foundation Trust & JS [2023] EWCOP 12. Judge found that once the MH Act authority expired, the person’s continuing restrictions triggered deprivation-of-liberty questions under the MCA. (Lesson: administrative lapse -> legal problem.) Court of Protection Hub

Stockport MBC v KB [2023] EWCOP 58 (reported analysis). Judicial analysis of community DoL applications and the kinds of medical evidence required (illustrates the court responding to poor or inconsistent local authority practice). Local Government Lawyer

Series of family/care cases on children (2022–2025). Lincolnshire CC v TGA (2022) spawned follow-on litigation and appellate correction in 2025; the arc shows local authorities and courts grappling with who may lawfully authorise confinement of children in their care. 39 Essex Chambers+1

Regulatory & statistical evidence. CQC: chronic DoLS backlogs and only 19% applications met statutory timescales (2023–24). LGSCO: formal findings that councils’ delays led to unlawful restriction in named investigations (e.g., Surrey). Ministry of Justice / court statistics: rising DoL applications and court challenges in 2024. Care Quality Commission+2Local Government Ombudsman+2

What this means for people and families (real effects shown in cases)

People have been left restricted for months without a lawful authorisation; families have been excluded from decision-making or told the only option is placement. Ombudsman and court reports give concrete examples of people moved long distances or denied contact because an adequate best-interests process was not carried out. Local Government Ombudsman+1

Conclusion — legal fixes are occurring, but slowly

Between 2023 and 2025 the courts have repeatedly had to step in to correct, fine-tune and sometimes rebuke local practice. The evidence is consistent: misuse is often not a deliberate plot but the predictable consequence of under-resourcing, inadequate training, inconsistent legal reasoning and the temptation to use deprivation orders as administratively convenient substitutes for proper social care packages. Appellate authorities (and the CQC/LGSCO) have pushed back, but only partly: operational backlogs and resource constraints mean the same problems recur across jurisdictions.

INNOCENT RELATIVES CAST AS PERPETRATORS BY THE OPG (OFFICE OF PUBLIC GUARDIAN)

November 9, 2025
Uncategorized
Leave a comment

Hidden in Plain Sight: The Secrecy and Power of the Office of the Public Guardian

The role of the Office of the Public Guardian (OPG) in England and Wales is, on paper, laudable. Tasked under the Mental Capacity Act 2005 with protecting some of society’s most vulnerable, the mentally incapacitated, those with severe illness or debilitation, its remit should command public trust. 

Yet for many families caught in its orbit, the reality has been something quite different: an opaque system, court-enforced gagging orders, accusations of wrongdoing levelled at innocent relatives, and little meaningful public scrutiny.

Secrecy by Default

The Court of Protection (CoP), which often works in tandem with the OPG when deputies are appointed or decisions made about capacity, remains shrouded in confidentiality. The legal framework makes it a contempt of court to publish a judgment unless the judge gives permission. As one commentary observed:

“We are finding that a significant minority of Transparency Orders prohibit identification of public bodies … for no apparent reason.” 

Practically speaking, this means families may find themselves accused of wrongdoing (or coerced into quiet settlement) while the processes, evidence and reasoning remain entirely hidden from view.

Worse still, these orders can apply to public bodies such as the OPG itself, insulating its decision-making from public scrutiny. 

Innocent Relatives Cast as Perpetrators

At the heart of the concern is that relatives, often the person closest to the vulnerable individual and already facing huge financial and emotional burdens are suspected, investigated or side-lined with minimal transparency. While specific names and dates are understandably anonymised, the patterns are evident:

Families recount being labelled as “concerned with their own interests” by the OPG or Court, despite no credible evidence of abuse.

The stress on relatives is profound. One family’s voice:

“We are all receiving medical help for the stress … it’s not stress due to my father’s illness – but due to all of this!” 

Although I could not locate a publicly-reported case in which a relative was definitively found innocent yet publicly cleared (owing to anonymity orders), the fact that the narrative of “accused relative” can proceed behind closed doors is deeply troubling. The system allows for a relative to be treated as a suspect, with the game largely hidden from view.

The Power Imbalance: Vulnerable Person vs State Apparatus

The vulnerable individual is meant to be the system’s focus. Yet the apparatus—OPG investigations, deputies, Court proceedings—can shift the locus of control away from the person and their trusted circle into a framework where state-appointed officials and judicial fiat dominate.

Some commentators argue the Court of Protection “institutionalises inequality … allows untested and hearsay evidence, restricts participation and disclosure” and thus risks breaching fair-trial standards. 

When trust and cooperation of relatives is replaced by suspicion and exclusion, the very aim of safeguarding may be undermined. Families describe how they are “never told what the goal-posts are”, “constantly moved on”, and prevented from simply being a family with their loved one. 

When the “Protector” Becomes the Gatekeeper

The OPG’s formal account of its investigative powers states that although around 2,800 investigations may be opened each year, “in most cases we find that there is no case to answer”. 

Yet this doesn’t mitigate the impact on those lives on which such investigations are launched. The act of being under investigation, being treated as a potential perpetrator, often sealed behind ‘confidentiality’, can itself be destructive: emotionally, financially and socially.

The official complaints procedure of the OPG emphasises responsiveness—aiming to reply within 10 working days, offering apologies and redress for proven mistakes.  But that only works after the damage is done. The system does little to ensuretransparency before or during the process which has the potential to pulverise a family’s trust and life.

Why It Matters

Transparency is not optional when the state effectively takes over personal decision-making, finances and care of those lacking capacity. Without clear oversight, power becomes unaccountable.

Relatives must not be collateral damage in protection systems. When a relative is treated as suspect, the family unit is fractured, and the very support the vulnerable person needs is compromised.

Public confidence in the guardianship framework demands more than good outcomes: it demands visible, understandable, and fair processes. The current veil of secrecy undermines deeper trust.

What Could Change

Defaults to openness: The CoP should adopt publication of hearings or summaries by default unless there is a compelling privacy reason—not the other way around.

Independent oversight: A body independent from the OPG should audit cases where relatives were investigated but cleared, ensuring learning and accountability.

Clearer pathways for families: When families are told they are “being investigated”, they should have the right to know the allegations, the evidence, and to respond—rather than being passive subjects.

Redress for families harmed by process: If a relative has been wrongly treated as a perpetrator, there should be accessible mechanisms for apology, compensation and restoration of name.

In Conclusion

The Office of the Public Guardian was established to protect those who cannot protect themselves. Yet somewhere along the way, the balance of power has shifted. Instead of championing the rights of the vulnerable, the system risks treating their trusted relatives as adversaries and cloaking its actions in near-total secrecy.

For a democracy that values dignity, justice and openness, this cannot stand. The very people who ought to be protected—the most vulnerable—deserve more than a system that operates behind locked doors. Families deserve more than the fear of being branded perpetrators without ever seeing the case against them.

The guardianship framework must be reformed not just in form but in spirit. And the public, including those whose voices are quieted by gagging orders must hold it to account.

DELAYED DISCHARGE

October 18, 2025
Uncategorized
Leave a comment

A delayed discharge case is when a patient is medically ready to leave a hospital but remains there for non-medical reasons. The delay can be caused by factors like a lack of available social care, insufficient community care packages, or issues with the hospital’s own processes. These delays are a major concern as they reduce hospital bed capacity, potentially leading to poorer patient outcomes and increased healthcare costs. 

Delayed discharges: why it’s hard to say how many are due to social care capacity

Authors

Here’s a multiple-choice quiz. What percentage of delayed discharges from hospital are caused by lack of adult social care capacity? Is it:

a) Most of them

b) 50%

c) 12%

d) There’s no way of knowing for certain.

The answer is d): we just don’t know. You get half a point if you said c) because 12% is the most we can definitely attribute to lack of social care capacity from the publicly available data. However, you’d be forgiven for thinking it was b) or even a) if you simply read the media coverage. In December, the Royal College of Nursing was quoted as saying that there was ‘barely a spare bed’ left in NHS hospitals due to a lack of capacity in social care; while in January, the NHS Confederation was reported as saying that 20% of NHS bed capacity was taken up by patients who were only there because they ‘cannot get a suitable care package’.

“Yet we don’t know the number – because, with the best of intentions, we chose to stop asking.”

Yet we don’t know the number – because, with the best of intentions, we chose to stop asking. In 2020, NHS England stopped separating out reasons for delay between health and social care. The reasoning, based on discussions with health and care organisations, was that delays were often complex, and instead of allocating them to one or other partner, systems should take responsibility, rather than individual sectors.

The most recent data recording, introduced in May 2024, requires discharge hubs (or sometimes wards) to classify the causes of delay into one of five categories:

  1. Hospital process (issues within the hospital’s control, such as medication or transport)
  2. Wellbeing concerns (issues outside the hospital’s control, for example where a family has doubts about a patient’s readiness for discharge)
  3. Care transfer hub process (most commonly where the patient’s destination has not yet been decided)
  4. Interface process (typically where transfer plans are underway but have not yet been completed)
  5. Capacity (where the service needed by the patient is not yet available).

Except for hospital process, all these categories include delays that are due to both the NHS and social care. For patients with stays of at least 14 days (the only publicly available measure), on average 9,309 people were delayed each day in March 2025. Of these, 3,203 delays were ascribed to ‘capacity’, followed by interface process (2,639), hospital process (1,754), care transfer hub process (1,200) and wellbeing concerns (514).

If we focus on those 3,203 capacity delays – because lack of social care capacity is often cited as a key cause of delayed discharges – the single largest reason (966 people delayed) is lack of ‘bed-based rehabilitation, reablement or recovery services’.

https://www.landmarkchambers.co.uk/news-and-cases/blog/health-and-social-care-law/delayed-transfer-of-care-leads-to-100k-legal-bill-for-an-icb

This covers a wide range of health and care services, some of which are commissioned by NHS trusts, some by local authorities and some jointly. Even discharge hubs would not be able to allocate them to ‘the NHS’ or ‘social care’. The same applies to ‘home-based rehabilitation, reablement or recovery services’ (502 people delayed), which again cannot be split neatly into social care or NHS.

In fact, only three of the sub-categories – lack of home-based social care services (257), lack of residential or nursing care (762), and people waiting for restart of existing social care services (63) – are solely attributable to social care. But these account for only 34% (1,082) of the 3,203 total ‘capacity’ delays and only 12% of the total 9,309 delayed patients. The real figure for social care delays will be higher because it will include some of the bed-based and home-based rehabilitation and reablement delays but is not counted.

“Yet the NHS and social care are two distinct systems, funded differently, usually commissioned differently and often with different immediate concerns.”

Author:

Into that data vacuum has emerged a range of guesses and estimates, some more authoritative than others. For example, in March NHS England told the House of Commons Health and Social Care Committee that around a fifth of bed days (note that this is a different measure to the publicly available one) lost to delayed discharge ‘are for individuals accessing adult social care packages on discharge’.

In an ideal world, it might not matter. Local systems would be working together to identify problems, avoiding blame and finding joint solutions. Perhaps most are already. Yet the NHS and social care are two distinct systems, funded differently, usually commissioned differently and often with different immediate concerns. On the NHS side, there is intense media and public concern about hospital capacity, A&E waits and ‘corridor care’. On the social care side, there is a longstanding grievance about lack of funding.

In these circumstances, it has sometimes suited both sides for lack of social care capacity to be seen as the key cause of hospital discharge delays. It allows social care to make the case for more money and deflects attention from the NHS causes of delay. This is why the headlines are tolerated, sometimes encouraged.

“It allows social care to make the case for more money and deflects attention from the NHS causes of delay. This is why the headlines are tolerated, sometimes encouraged. ”

Author:

Yet it can still rankle within social care if it is held largely responsible for a problem to which it is, in fact, only a minority contributor. There is a long and inglorious tradition of blaming social care for hospital discharge delays.

There is also irritation about the word ‘capacity’: there is plenty of capacity in care homes, says the sector (occupancy has still not quite returned to pre-pandemic level); the issue is that commissioners (in both the NHS and local authorities) are not sufficiently well organised and are unable or unwilling to pay a fair price for it.

In this difficult environment, avoiding a blame game on hospital discharge was always going to be ambitious. It’s proved to be that – and more. Time to accept reality and publish a credible official estimate of the respective responsibilities for delayed discharge of health and social care.

Further reading

ADULTS & COMMUNITY WELLBEING SCRUTINY MEETING MINUTES AND JUSTIFICATION FOR PATHOLOGICAL TESTS IF IN DOUBT

January 31, 2025
Uncategorized
Leave a comment

Held at:County Offices, Newland, Lincoln, LN1 1YL Extract from Minutes of the Adults and Community Wellbeing Scrutiny Committee Lincolnshire County Council
A meeting of the Adults and Community Wellbeing Scrutiny Committee took place on Wednesday, 4 September 2024 at 10.00 am in the Council Chamber, County Offices, Newland, Lincoln LN1 1YL.
Debbie Barnes OBE Chief Executive.

The Minutes stated:
“Many older adults may have been misdiagnosed with mental health issues for decades, often leading to a misunderstanding of their true cognitive and emotional needs. Data was being gathered on these individuals, especially those with learning disabilities, who tend to be identified earlier in their lives, allowing for potentially more effective interventions. However, despite this positive trend, there were significant challenges in the system???? The Integrated Care Board (ICB) recognized the need for immediate action and funded various services for 16-18 year olds, aiming to create a streamlined pathway for young individuals needing support. Unfortunately, there is a national issue with excessively long waiting lists for neurodevelopmental services, which further complicated access to necessary care. Waiting times for diagnosis were reported to be up to a year (4 IN ELIZABETH’S CASE) locally for those seeking help; in some regions, it could extend to an alarming seven years elsewhere, exacerbating the situation and leaving many individuals without the support (AND CORRECT TREATMENT) they desperately needed. This stark discrepancy highlights not only the urgent need for improvements in service delivery but also the importance of re-evaluating how mental health and developmental disorders are diagnosed across different age groups.”

In Elizabeth’s case, Developmental was mentioned in the first instance and as far back as 2007 scans were not normal. Being denied pathological tests goes well beyond a year – over a lifetime combined with former area, well before moving but now detention under the MHA is in its fourth year and there should therefore be no excuses for any further delays for essential neurological tests. What is the point in a CTR that does not review treatment effectively, excluding physical health and family for a vulnerable person held long term under MH for following reasons:

When is Referral for Neurological Testing Necessary?

Referral for neurological testing may be clinically indicated in several situations, including but not limited to:

Neurological symptoms such as persistent headaches, dizziness, weakness, visual disturbances, or cognitive changes.

Manifestations of seizures or fits or neurological reactions to stimuli or potential allergens. 

Red flag symptoms indicating serious underlying conditions like a brain tumour, stroke, or multiple sclerosis.

Unexplained neurological signs after an injury or trauma, particularly head injuries, where a clinician might suspect a neurological disorder.

If a responsible clinician fails to refer a patient when such symptoms or red flags are present, and that failure leads to harm (e.g., delayed diagnosis of a serious neurological condition), there may be grounds for a negligence claim. 

A clinician might be at risk of a negligence claim if they fail to refer a patient for neurological testing when clinically indicated, especially if such a failure leads to harm that could have been avoided with appropriate testing and treatment. 

It is every bit possible that Elizabeth has been subjected to many years of inappropriate treatment due to faulty diagnosis and huge amounts of endocrine disrupting drugs, not to mention many years deprivation of liberty that could have been avoided with a more thorough medical examination. 

Case law, such as A v East of England Ambulance Service NHS Trust, emphasizes that clinical decisions must align with accepted medical practices. If a clinician’s actions are within the range of what a responsible body of medical professionals would consider reasonable, they are less likely to be found negligent. However, if their failure to refer deviates from such standards and causes harm, they could be held liable.

A v East of England Ambulance Service NHS Trust [2017] UKSC 19:

This case concerned whether a medical professional breached their duty by failing to appropriately investigate or respond to a patient’s symptoms. Although it was about a failure in emergency care, it emphasizes the importance of considering the duty to investigate symptoms properly and the risks of failing to do so. A clinician failing to refer a patient for neurological testing might be considered negligent if it can be shown that such an investigation was warranted by the patient’s presentation.

The Bolitho v City and Hackney Health Authority[1997] 3 WLR 1151 case is a key ruling in clinical negligence law, refining the Bolam test (from Bolam v Friern Hospital Management Committee [1957]).

Ruling in Bolitho:

In this case, the House of Lords considered whether a doctor was negligent for failing to attend a child in respiratory distress, despite being called to do so by nursing staff. The doctor’s absence allegedly led to the child’s death.

The central issue was whether the doctor’s decision not to attend could be justified by the standard of practice accepted by a responsible body of medical opinion (the Bolam test). In other words, was the failure to attend a reasonable decision, according to the practices of a responsible group of doctors?

The House of Lords held that the Bolam test is not an absolute shield for professionals. Although medical practice is determined by the opinion of a responsible body of medical professionals, this does not mean that any opinion, however unreasonable, will be accepted. Courts have a role in ensuring that the medical opinion is “logical and defensible”. In essence, the court can reject a medical opinion if it is deemed illogical or irrational.

Summary of the Key Points:

The Bolitho ruling clarifies that medical professionals’ practices must be reasonable and defensible. Courts will scrutinize the validity of medical opinions in negligence cases.

It made clear that even if a practice is accepted by a body of medical professionals, if that practice is not supported by a logical or reasonable explanation, it cannot be relied upon to defend against a negligence claim.

The decision to not attend the patient in Bolitho was deemed negligent because the medical practice relied upon did not have a logical basis.

So what is the ‘logical basis’ for not sending Elizabeth for tests when they are clearly needed?

The Bolitho decision thus refined the Bolam test, adding an element of judicial oversight to ensure medical opinions are reasonable and coherent, not merely accepted by a group of professionals.

Diagnostic error in mental health: a review Bradford A, et al. BMJ Qual Saf 2024;33:663–672. doi:10.1136/bmjqs-2023-016996

There is sufficient evidence here already to link the lesions and resultant inflammation with what they misdiagnose as schizophrenia and this is even evident in Elizabeth’s former doctor’ s work: Dr Shahpesandy.

Dr Shahpasandy’s Research :

It is scandalous that with the number of patients known to be misdiagnosed that there is not a root and branch re-examining of mental health assessments. It is not psychiatrists and AMPHs who should have exclusive domaine here.  The examination is nowhere near complete without a thorough neurological and immunological/endocrinological examination.  Our national mental health policy is entirely in the sway of psychiatrists and drug companies.   

A failure in pathophysiological testing for organic contributions can significantly contribute to the prevalence of misdiagnosis in schizophrenia. Reports and studies have indicated that the prevalence of misdiagnosis in schizophrenia can be significant, with estimates often cited in the range of 10% to 40%, depending on the specific context, population, and research methodology. 

Given the complexities of diagnosing schizophrenia, it is crucial for mental health professionals to use comprehensive assessment approaches to enhance diagnostic accuracy and reduce the likelihood of misdiagnosis.

Lack of Comprehensive Assessment: 

Many clinicians do not conduct thorough pathophysiological assessments, such as neurological evaluations and laboratory tests, which can lead to missing underlying medical conditions that mimic or contribute to psychiatric symptoms.  Some clinicians over emphasise the subjective nature of psychotic disorders and actively discourage proper pathophysiological assessments. 

Overlapping Symptoms: 

Certain medical conditions (e.g., infections, autoimmune disorders, endocrine abnormalities) can present symptoms similar to those of schizophrenia. Without appropriate testing, these conditions may be misidentified as primary psychiatric disorders.

Neuroimaging and Biomarkers: 

Advances in neuroimaging (like MRI or CT scans) and the discovery of potential biomarkers for various conditions are important for identifying organic contributions to psychosis. If these tools are not utilized, it can result in misdiagnosis.

Co-Occurring Disorders: 

When an underlying medical condition is present alongside schizophrenia, it may complicate the clinical picture and lead to misunderstanding or misattribution of symptoms, resulting in a misdiagnosis.

Education and Awareness: 

Clinicians may not always consider organic causes when diagnosing schizophrenia, especially if they lack training or awareness about how medical issues can manifest as psychiatric symptoms.

Stigma and Assumptions: 

There may be an inclination to diagnose psychiatric conditions like schizophrenia without sufficiently exploring organic causes, particularly in patients with risk factors for mental illness, leading to overlooking potential medical diagnoses.

Case Reports: 

Numerous case studies and reports highlight instances where patients initially diagnosed with schizophrenia were later found to have organic pathologies, emphasizing the necessity of pathophysiological testing in uncertain cases.

Inadequate pathophysiological testing increases the likelihood that clinicians may overlook organic contributions to a patient’s symptoms, leading to a higher prevalence of misdiagnosis of schizophrenia. Comprehensive evaluation approaches that integrate both psychiatric and medical assessments are essential for accurate diagnosis and effective treatment.

The misdiagnosis of schizophrenia can occur for several reasons, but the following are some of the main contributing factors:

Symptom Overlap: 

Schizophrenia shares symptoms with various other mental health disorders, such as bipolar disorder, major depressive disorder, and personality disorders. This overlap can lead to confusion and misdiagnosis.

Incomplete Clinical History: 

A thorough assessment requires a detailed clinical history, including past medical and psychiatric treatments. When this information is lacking or overlooked, it frequently leads to inaccuracies in diagnosis.

Subjective Assessment: 

Psychiatric diagnoses often rely on subjective assessments of symptoms and behaviours. Variability in how clinicians interpret and diagnose these symptoms can result in inconsistencies and misdiagnosis.

Lack of Awareness or Training:

Some clinicians may not be adequately trained to recognize the nuances of schizophrenia or the range of conditions that can mimic its symptoms, leading to incorrect diagnoses.

Stigma and Assumptions: 

Societal stigma surrounding mental illness may lead to hasty or biased conclusions, particularly in emergency settings where rapid assessments are made under stress.

Co-occurring Disorders: 

Many individuals with schizophrenia may have co-occurring disorders (e.g., substance use disorders, anxiety disorders), complicating the clinical picture and leading to misdiagnosis.

Cultural Factors: 

Cultural differences in the expression and interpretation of symptoms can affect diagnosis. Clinicians may misinterpret culturally specific symptoms as pathological.

Insufficient Diagnostic Tools: 

While there are diagnostic criteria (like DSM-5 or ICD-10), there are no objective tests (e.g., blood tests or imaging) to confirm a schizophrenia diagnosis, leading to a over-reliance on observed behaviours and self-reported symptoms.

These factors highlight the need for comprehensive assessments and clinical awareness to reduce the rates of misdiagnosis in schizophrenia.

Failing to conduct thorough pathophysiological tests when diagnosing schizophrenia can have several significant serious consequences:

Misdiagnosis: 

Schizophrenia shares symptoms with other mental health disorders such as bipolar disorder, depression, and schizoaffective disorder. Without comprehensive testing, there’s a risk of misdiagnosing the condition, leading to inappropriate treatment plans.

Inappropriate Treatment: 

Inaccurate diagnosis can result in prescribing incorrect medications, which might not alleviate symptoms and could cause adverse side effects. Patients might also miss out on the benefits of effective therapeutic interventions tailored to their actual needs.

Delayed Treatment: 

Insufficient testing might delay the correct diagnosis, postponing necessary interventions. Early and accurate diagnosis is crucial for effective treatment, and any delay can worsen prognosis and lead to more significant deterioration in quality of life.

Poor Prognosis: 

Without targeted interventions, patients may experience worsened symptoms and a decline in functioning. More comprehensive evaluations can help identify specific needs and comorbid conditions, which are integral in planning effective management strategies.

Increased Healthcare Costs: 

Misdiagnosis or delayed diagnosis can lead to increased healthcare costs due to unnecessary treatments, potential hospitalizations, and more extensive long-term care due to unmanaged symptoms.

Impact on Quality of Life: 

The individual may suffer from ongoing symptoms that could affect their daily life, social relationships, and occupational functioning. Effective treatment hinges on an accurate diagnosis, allowing patients to manage symptoms and improve their overall quality of life.

CAVERNOMAS

A thorough diagnostic process, including pathophysiological tests are necessary and help ensure that patients receive the right diagnosis and appropriate treatment, improving outcomes and reducing the burden of the disease.

A cavernoma, which is a type of vascular malformation in the brain, can potentially interfere with neurotransmission and lead to symptoms that might be misinterpreted as psychosis. Cavernomas are clusters of abnormally formed blood vessels that can disrupt normal brain function by causing bleeding, inflammation, or other structural changes.

Cavernomas, especially in areas like the temporal lobe, can cause seizures. Seizures can sometimes present with confusion, disorientation, or altered perceptions, which could be mistaken for psychotic symptoms. For example, if the cavernoma causes focal seizures, these could manifest as hallucinations, paranoia, or delusions, which are all features of psychosis.

Cavernomas, depending on their location, can affect areas of the brain responsible for cognition and emotion regulation. If a cavernoma leads to functional changes in these regions, it could cause alterations in behaviour or mood, potentially resembling symptoms of a psychiatric disorder.

A cavernoma can disrupt the normal flow of neurotransmitters in the brain, especially if it causes local damage to nerve cells or interferes with blood supply. Neurotransmitter imbalances can contribute to mood swings, hallucinations, or altered perceptions, which may be mistaken for psychotic episodes.

In some cases, the physical stress and changes caused by a cavernoma, such as chronic headaches, seizures, or neurological deficits, can also lead to psychiatric symptoms, such as anxiety, depression, or even psychotic-like symptoms. These may be misdiagnosed as primary mental health issues.

Given these possibilities, a thorough neurological evaluation, including imaging studies like an MRI, is crucial for distinguishing between a primary psychiatric disorder and a neurological condition like a cavernoma. If psychosis-like symptoms are present, a neurologist or psychiatrist should look at a range of factors to rule out any underlying brain pathology, including vascular malformations like cavernomas.

The misdiagnosis of schizophrenia due to underlying brain lesions or cerebral inflammation is a known but relatively underreported phenomenon. Although schizophrenia is primarily considered a psychiatric disorder, its symptoms can overlap with neurological conditions that cause similar cognitive and behavioural disturbances, like brain lesions, inflammation, or other structural abnormalities.

Cerebral inflammation and brain lesions, such as those caused by vascular malformations (like cavernomas), brain tumours, endocrine disorders and autoimmune diseases, can lead to cognitive impairments, mood disturbances, hallucinations, or delusions, which are also hallmark symptoms of schizophrenia. When these neurological issues are undiagnosed, individuals may be misdiagnosed with a primary psychiatric condition like schizophrenia, especially if there’s a lack of awareness about the neurological possibility.

As for the estimated incidence of misdiagnosis, studies suggest that it’s not uncommon for neurological disorders to be misdiagnosed as psychiatric conditions. A few estimates suggest that about 15-25% of individuals initially diagnosed with schizophrenia may actually have an underlying neurological condition, though this figure can vary widely depending on the specifics of the study and the healthcare setting. In some cases, lesions or inflammation are only discovered after further neurological and pathophysiological testing (e.g., brain imaging, MEG, EEG and inflammatory marker evaluation), which can shift the diagnosis.

However, it’s worth noting that schizophrenia has a distinctive clinical picture, and misdiagnosis tends to occur more often in cases where symptoms are atypical or the neurological signs are subtle. When there is clear evidence of brain lesions, seizures, or other neurological symptoms, a more comprehensive diagnostic approach (including imaging) usually helps differentiate between psychiatric disorders and neurological conditions.

Cerebral inflammation can indeed cause symptoms that may be misdiagnosed for psychotic disorders, especially when the inflammation affects areas of the brain responsible for cognition, mood, or perception.

Conditions that cause inflammation in the brain—such as autoimmune disorders, infections (e.g., encephalitis), neurodegenerative diseases, endocrine disorders or even conditions like multiple sclerosis—can lead to psychiatric symptoms such as delusions, hallucinations, mood swings, and confusion. These symptoms can overlap with those seen in psychotic disorders like schizophrenia or bipolar disorder with psychotic features.

Misdiagnosis and how it can be avoided:

Overlap of Symptoms

Inflammation in the brain can cause hallucinations, delusions, agitation, and paranoia, which are core symptoms of psychotic disorders.

Disorders like autoimmune encephalitis can cause severe mood swings, depression, or mania, which can sometimes be mistaken for mood disorders with psychotic features.

Problems with memory, concentration, and thinking (often seen in inflammation-related brain conditions) can be confused with cognitive symptoms seen in psychotic disorders.

Differentiating Between the Two

To avoid a misdiagnosis, it’s crucial to conduct a comprehensive medical evaluation. This should include a detailed history (e.g., recent infections, autoimmune history, or neurological symptoms), a physical exam, and neuroimaging (like MRI, MEG, EEG or CT scans) to look for signs of brain inflammation or structural abnormalities.

Certain blood tests or cerebrospinal fluid (CSF) tests may help identify markers of inflammation or infection in the brain. Elevated levels of certain proteins or antibodies can be suggestive of neuroinflammatory conditions. In some cases, cognitive testing can help distinguish between psychosis due to a psychiatric disorder versus cognitive dysfunction related to brain inflammation.

Sometimes, clinicians will assess how the patient responds to treatments. If psychosis is related to inflammation, it may improve with steroids, immunotherapy, or antiviral medications, which are typically ineffective for primary psychiatric disorders.

Specific Conditions to Consider

One condition that commonly mimics psychiatric disorders is autoimmune encephalitis, which can cause rapid onset psychosis, mood disturbances, and confusion. Testing for autoantibodies (like anti-NMDA receptor antibodies) can help in diagnosing this condition.

Infections such as encephalitis, meningitis, or even HIV/AIDS-related encephalopathy can cause psychiatric symptoms and should be ruled out.

MS can sometimes cause psychiatric symptoms like depression, anxiety, and psychosis due to demyelination in certain brain areas. This can be distinguished from primary psychotic disorders through MRI scans showing characteristic lesions.

Minimizing Misdiagnosis

A team approach involving both neurologists and psychiatrists can help ensure a more accurate diagnosis when symptoms overlap.

A careful review of a patient’s medical history, including autoimmune conditions, infections, or a history of trauma, can help guide clinicians toward the right diagnosis.

If symptoms of psychosis arise suddenly or change in an unusual manner, it can raise suspicion for a medical cause rather than a primary psychiatric disorder. The timeline of symptom onset, course, and any precipitating factors (like infections or medications) should be taken into account.

Ultimately, a comprehensive diagnostic workup is essential to distinguish between cerebral inflammation and psychotic disorders. Early recognition and treatment of conditions causing brain inflammation can prevent further complications and ensure that patients receive the most appropriate care.

Link to Endocrine Disorders:

If a cavernoma is located near or within areas of the brain involved in endocrine regulation, it could theoretically contribute to endocrine dysfunction. These areas include:

  1. Hypothalamus: The hypothalamus plays a central role in regulating the endocrine system via its control over the pituitary gland. A cavernoma in this region could disrupt hormone regulation and lead to a variety of endocrine disorders, such as:
    • Hypothalamic dysfunction (e.g., issues with temperature regulation, hunger, or thirst).
    • Dysregulation of pituitary hormone release (e.g., corticotropin, growth hormone, gonadotropins).
  2. Pituitary Gland: Cavernomas affecting or compressing the pituitary gland could lead to:
    • Hypopituitarism (reduced secretion of pituitary hormones).
    • Hyperprolactinemia (if pressure disrupts the inhibition of prolactin secretion).
    • Other imbalances depending on the specific hormones affected.
  3. Other Brain Regions with Secondary Effects:
    • Cavernomas causing significant intracranial pressure, hemorrhage, or secondary damage might indirectly affect endocrine function by impairing brain structures or pathways.

Rare but Documented Cases:

Although cavernomas are not commonly associated with endocrine disorders, there are reported cases of cavernomas near the hypothalamic-pituitary axis causing endocrine dysfunction. These cases emphasize the importance of the cavernoma’s size, location, and potential for bleeding or compression.

Symptoms to Monitor:

If an individual with a cavernoma develops symptoms suggestive of endocrine dysfunction, such as fatigue, unexplained weight changes, menstrual irregularities, or growth abnormalities, a detailed evaluation is warranted. This may include:

  • Hormonal blood tests.
  • High resolution imaging studies like MRI to assess the cavernoma’s location and size.

Conclusion:

While cavernomas do not inherently cause endocrine disorders, those located in or near endocrine-regulating brain regions (like the hypothalamus or pituitary gland) have the potential to disrupt hormonal function. It’s essential to work with a neurologist and endocrinologist to address these concerns.

Elizabeth has a recognised endocrine disorder which can lead to the effects below.  The two hormones (neurosteroids) allopregnanolone and pregnenolone may be affected by the disrupted endocrine function and the levels of these should be tested.  I consider it unlikely they have even considered this just like they have ignored the inflammatory markers that can cause limbic encephalitis.  

They ignore all of these studies even when they are written by their own people like Dr Shahpesandy.  Lots of people are detained on wards who would be able to be discharged if they were given hormonal supplements and anti-inflammatories.  Even Shahpesandy acknowledges that.   

Idiotic prescribing of anti-psychotics will in some cases make endocrine dysfunctions worse and benzos given as prnrapid tranquillisation can cause limbic inflammation. 

Low levels of allopregnanolone and pregnenolone can contribute to psychiatric symptoms, including mood disturbances and, in some cases, psychotic symptoms. These neurosteroids play essential roles in stabilizing mood, reducing anxiety, and modulating stress responses, and they can be impacted by certain endocrine disorders. Here’s a closer look at how these neurosteroids interact with mental health and endocrine function:

Allopregnanolone and Pregnenolone in Mental Health

Allopregnanolone is a potent positive modulator of GABA-A receptors, which are central to calming neural activity and reducing anxiety. It helps create a sense of stability in brain signaling, counteracting overstimulation and stress. Low allopregnanolone levels have been associated with anxiety disorders, depression, and increased stress sensitivity.

Pregnenolone serves as a precursor to other neurosteroids, including allopregnanolone, and has its own neuroprotective effects, including modulating NMDA receptors and potentially balancing dopamine and GABA neurotransmission. It has been studied in relation to schizophrenia and other psychotic disorders, as low pregnenolone levels may contribute to cognitive impairment and psychosis.

Potential for Psychotic Symptoms

While low allopregnanolone and pregnenolone levels alone aren’t generally thought to cause psychosis directly, a deficiency in these neurosteroids can create vulnerability to psychotic symptoms, especially in those with predispositions or other stressors.

Neurosteroids like pregnenolone have been linked to dopamine modulation. Dopamine dysregulation is a hallmark of psychosis, particularly in conditions like schizophrenia. Reduced pregnenolone levels may therefore impact dopamine balance and contribute to hallucinations, delusions, and thought disorders.

Some research also suggests that allopregnanolone may have a stabilizing effect on mood and perception; reduced levels might leave individuals more susceptible to stress, which in extreme cases could precipitate psychotic-like symptoms in vulnerable individuals.

Low Neurosteroid Levels and Endocrine Disorders

Adrenal insufficiency (e.g., Addison’s disease) and other endocrine disorders affecting adrenal or gonadal hormones can reduce the availability of precursors needed for neurosteroid synthesis. This can lead to low levels of allopregnanolone and pregnenolone.

Disorders of the hypothalamic-pituitary-adrenal (HPA) axis, including chronic stress and HPA axis dysregulation, can also result in altered neurosteroid production. Chronic stress suppresses the production of pregnenolone and can shift steroid synthesis toward stress hormones like cortisol rather than neurosteroids.

Polycystic Ovary Syndrome (PCOS) and other hormonal imbalances involving estrogen progesterone may disrupt neurosteroid synthesis, as these hormones are involved in the pathways that produce pregnenolone and allopregnanolone. Individuals with PCOS, for example, have an increased risk of mood disorders, which may be partly related to altered neurosteroid levels.

Clinical Implications and Potential Treatments

Understanding low neurosteroid levels as part of a broader endocrine issue can help target treatments more effectively. Hormone replacement therapy (HRT) or neurosteroid analogs are sometimes used to restore balance in individuals with chronic deficiencies.

Pregnenolone supplementation has shown potential as an adjunctive treatment for schizophrenia and mood disorders, with some studies suggesting it can help reduce symptoms of anxiety, cognitive deficits, and even mild psychosis.

Similarly, allopregnanolone analogs, like brexanolone (approved for postpartum depression), are being explored for their potential to help with other mood and anxiety disorders, offering a novel approach to neurosteroid-based therapy.

Summary

In conclusion, low levels of allopregnanolone and pregnenolone can contribute to psychiatric symptoms, including psychosis, especially in individuals with underlying vulnerability. These deficiencies are indeed symptomatic of certain endocrine disorders, especially those affecting adrenal or sex hormones. Addressing neurosteroid imbalances through hormone therapy, neurosteroid analogs, or other supportive measures can be beneficial in managing symptoms linked to these deficits.

It is appalling that when you as a carer ask for pathological tests you are up against huge bullying and then safeguarding against you. There is no safeguarding towards the vulnerable person who needs the extensive pathological tests or for anyone whose diagnosis is in doubt denied such tests for many years. I know I am not alone in this matter and in the Scrutiny Meeting Minutes it actually highlights a national problem that needs urgent changes as if ignoring the necessity for such tests as so many lives are put at risk.