Ombudsman upholds complaint against charity commissioned by Cambridgeshire council over long-term sedative drug prescriptions

A complaint that a health and social care charity commissioned by Cambridgeshire County Council (CCC) prescribed sedative drugs to patients long-term against national guidance and its own prescribing policy has been upheld.

Change Grow Live (CGL) gave three patients long-term prescriptions for benzodiazepines, a class of drug that includes diazepam or Valium, without fully recording the reasons for doing so, the Local Government and Social Care Ombudsman (LGSCO) said in a report upholding the complaint.

The drugs, which are typically prescribed to treat conditions such as anxiety, are usually only prescribed short-term, particularly because they can become addictive.

CGL “caused avoidable uncertainty about the management of clients prescribed long-term benzodiazepines” by failing to keep full and up-to-date records about their patients' prescriptions, the LGSCO concluded after investigation, adding that both the charity and the council have accepted its findings.

CGL, whose services are commissioned by 50 other councils in England, has also said it will provide LGSCO with the results of a national clinical audit of its benzodiazepine prescribing.

This will help “identify cases where injustice may already have been sustained” among the 343 other CGL patients on long-term benzodiazepine prescriptions, the ombudsman says.

CGL’s Cambridgeshire audit was carried out in September 2022 after the ombudsman received the complaint; this showed that three of the nine patients in the region with a long-term Valium prescription had no “recorded rationale” for this.

The charity also confirmed during this audit that all three patients had benzodiazepine dependence syndrome and had come to them for this reason; it was not CGL that had initially prescribed it.

One had recently completed a detox from alcohol and agreed to start a Valium reduction programme, CGL said, while another was reluctant to reduce Valium while also reducing methadone and would need mental health support before doing so. The third agreed to a reduction program after CGL’s audit.

The LGSCO found that CGL’s actions were not in keeping with the Health and Social Care Act’s regulations around record-keeping or its own ‘Management of Benzodiazepines Procedure’, which includes encouraging regular audits to ensure everyone taking Valium long-term is on a reduction scheme and prioritising reducing the use of this over long-term methadone prescriptions.

But another review, undertaken by a specialist pharmacist and commissioned by the council, concluded that the drugs were prescribed in line with the NICE (National Institute for Health and Care Excellence) guidelines, but it also said that record-keeping needed to be improved.

This helped lead to the LGSCO’s conclusion that there was “fault by CGL which acted for the Council” and that its records resulted in "unavoidable uncertainty".