Pennine Acute Hospitals NHS Trust

2. Miss B complains about aspects of care and treatment her mother, Mrs A, received from the Pennine Acute Hospitals NHS Trust (the Trust) from 25 October 2017. Miss B says the Trust gave her mother morphine and midazolam. Miss B says the midazolam caused her mother to go into a comatose state, which she continued to remain in, until her death on 1 November 2017. In the correspondence Miss B received in February 2018, she says the Trust only referred to morphine and did not record in her mother’s medical records which medication she was given.

3. Miss B and her family believe that her mother died sooner than she should have and the medication given by the Trust led to her mother’s premature death.

4. As an outcome, Miss B is seeking an apology, acknowledgement of failings and service improvements.

5. On 25 October 2017 Mrs A was admitted to the Emergency Department (ED). She was an elderly woman with Chronic Obstructive Pulmonary Disease (COPD), type two respiratory failure, type two diabetes, acute kidney injury and congestive cardiac failure.

6. On 26 October 2017, after discussions with Mrs A’s family (Miss B disputes any discussions took place) and a rapid deterioration in her health, the Trust determined she required ‘end of life’ care.

7. On 1 November 2017 Mrs A sadly died. The cause of death was documented as type two diabetes and cardiac failure.

10. We should begin by saying how sorry we were to learn of the circumstances which led to this complaint. We have no doubt the events which took place have significantly impacted Miss B and the rest of her family. She has told us she has found it difficult to move on from these events, especially as her mother had always asked not to be allowed to die in hospital. We can therefore understand her shock and upset in seeing Mrs A deteriorate so soon after her admission.

Midazolam

11. Miss B has said the Trust administered her mother with morphine and midazolam. She told us the midazolam caused her mother to go into a comatose state which led to the rapid decline in her health.

12. Midazolam is commonly used to manage symptoms of confusion and restlessness at the end of life. Our adviser explained midazolam is usually started at 10mg over the first 24 hours and can be increased up to 60mg over the next 24 hours. This is evidenced by British National Formulary guidance on midazolam usage.

13. Our adviser went on to explain from the evidence available Mrs A was sadly nearing the end of her life and therefore the Trust started her on a dose of 10mg which was increased to 20mg based on her requirements. They explained that the Trust reviewed Mrs A daily and increased her dosage in line with her requirements. Our adviser noted when treating end of life symptoms, 20mg is a relatively low dose of midazolam.

14. Therefore, from the evidence we have seen, we are satisfied the Trust acted appropriately and in line with relevant guidance.

15. We then asked our adviser whether there were indications to suggest midazolam caused Mrs A to go into a comatose state.

16. We found Mrs A was deteriorating in health following her admission and was sadly dying.

17. Our adviser explained that during the end of life process, symptoms of restlessness and agitation are common and distressing for the patient. This is specifically the case in respiratory disease such as COPD when the patient cannot manage their respiratory secretions and breathing becomes difficult.

18. Midazolam has a sedative and calming effect. Mrs A was monitored hourly as per the clinical records and was settled with the medications that the Trust administered. This could be interpreted as ‘comatose’ by family. However, it would be very distressing for the patient to leave her agitated, struggling to breathe and in pain at the end of her life.

19. As such, the midazolam would have had a sedating effect on Mrs A, but it did manage any agitation. Again, it appears the use of midazolam was appropriate and in line with British National Formulary guidance.

Documentation of medication

20. The clinical records show the medications the Trust administered and the doses of those medications over a 24-hour period. The records show the rate of infusion and the times and dates the Trust administered them. This includes midazolam.

21. As such, it appears the records were correctly completed In line with NMC standards (section 10, record keeping).

Summary

22. We are extremely sympathetic to the family’s concerns about Mrs A’s treatment in the final days of her life. However, we have seen nothing to suggest we should uphold the complaint.

23. We know this is not the outcome Miss B or her family were looking for when they complained to us. Miss B has told us how deeply these events have affected her, and we realise there is little we can say to remove the pain she has so obviously felt at her mother’s sad death. We hope that our report goes some way to addressing her concerns and gives her some assurance that, despite sad events, the Trust treated her mother appropriately.

1. From all the evidence we have seen and considered throughout our investigation, our final decision is to not uphold the complaint. Although we appreciate the upsetting circumstances surrounding Mrs A’s death, we are satisfied the Trust appropriately administered midazolam in line with national guidance and recorded this correctly in her clinical records. We also found no evidence to suggest the actions of the Trust resulted in Mrs A entering a comatose state.