Man suffered psychotic episode ‘for weeks’ after being prescribed new drug

A man was not warned about the side-effects of a new medicine before he suffered a psychotic episode which led to him having hallucinations of bears and burglars, a watchdog has said.

The Parliamentary and Health Service Ombudsman (PHSO) said Andrew Holland was “not fully informed” when he was prescribed prednisolone – a type of steroid.

Mr Holland suffered a psychotic episode which lasted for weeks after he was prescribed the drug at Manchester Royal Eye Hospital in 2022 to treat inflammation in his eye.

The 61-year-old, from Manchester, began suffering disrupted sleep and severe headaches after starting the drug.

He then became aggressive, psychotic and was “inexplicably wandering the street at different times of the day and night”, the PHSO said.

Mr Holland began seeing hallucinations which left him “confused and scared”, the ombudsman added.

“I was seeing all sorts… there was a bear at the end of the garden one day and a burglar coming over the garage roof,” Mr Holland said.

“I just took what they told me to take. I wouldn’t like to go through that again and I wouldn’t wish it on anyone either.”

After several hospital visits for symptoms, he was diagnosed with steroid-induced psychosis, and later steroid mania.

The PHSO said there was a “missed opportunity to fully inform (Mr Holland) of potential extreme side-effects” of his medication and it recommended that Manchester University NHS Foundation Trust pay £700 compensation in recognition of the distress and worry he experienced.

PHSO chief executive Rebecca Hilsenrath said: “This must have been a terrifying experience. It is an act of trust to put yourself under the care of others, and trust depends on information and understanding.

“No-one wants to suffer a psychotic episode – no-one should do so as a result of medication without fully understanding and accepting the risk.”

Patient safety information leaflets for prednisolone tablets (1mg and 5mg) state that “mental health problems can happen while taking steroids like prednisolone”.

The leaflet adds: “Steroids including prednisolone can cause serious mental health problems. These are common in both adults and children. They can affect about five in every 100 people taking medicines like prednisolone tablets.”

These can include feeling, seeing or hearing things which do not exist and having strange and frightening thoughts.

A spokesman for Manchester University NHS Foundation Trust said: “We would again apologise to Mr Holland for this incident two years ago, where the care we provided didn’t meet the high standards which we expect.

“We have made changes since that time, but we will carefully study the ombudsman’s ruling to assess if more learning can be taken from it to further improve our services.”