Northern Lincolnshire and Goole NHS Foundation Trust

4. Mr H complains the Trust should not have given diazepam to his mother covertly and against her wishes on 21 April 2019. He also complains diazepam was an unsuitable medication because it slowed his mother’s breathing and contributed to her death an hour later.

5. Mr H says the Trust’s actions caused him distress and worry. His says his mother’s death might have been avoided, and this has caused him and his family considerable grief.

6. Mr H wants the Trust to acknowledge what went wrong, apologise for the impact of this, and put in place improvements so this does not happen again. He would also like it to pay him a financial remedy in recognition of the impact of its actions.

7. Mrs H was admitted to hospital at the Trust on 19 April 2019, where she was diagnosed with a chest infection, which resulted in type 2 respiratory failure. This occurs when the lungs cannot absorb enough oxygen or breathe out enough carbon dioxide, so it builds up in the blood and becomes toxic.

8. On 21 April Mrs H’s condition worsened. The doctors felt she was critically unwell and could die. She moved to the Trust’s high dependency unit and started non-invasive ventilation (NIV). NIV uses a machine that helps air move in and out of the lungs more easily, through a tightly fitted face mask.

9. Mrs H was becoming increasingly agitated and would not tolerate the NIV mask. As she would not wear the mask, the Trust used high flow nasal oxygen (HFNO) as an alternative. This delivers fast, high concentrations of oxygen through a specialist tube into the nose.

10. Mrs H became more agitated and pulled off the HFNO. That afternoon, the nurses tried to give her some diazepam tablets, but she refused them. The nurses spoke to the doctors for advice, and they said the nurses could give Mrs H a covert injection of diazepam.

11. The nurses did, and it appeared that afterwards Mrs H settled down enough to keep her oxygen on.

12. Around an hour later Mrs H asked to use the commode but needed to stay in bed because she was too unwell to get up. She wanted to be made comfortable in the bed instead. While the staff were attending to Mrs H, she became unresponsive and, sadly, died.

16. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.

17. Mr H complains diazepam was an unsuitable medication to give to his mother because it slowed her breathing and contributed to her death an hour later. He also says diazepam should not have been given against his mother’s wishes after she refused it.

18. The respiratory failure guidelines set out what should happen when a person receiving NIV treatment becomes agitated and stops tolerating it. They say benzodiazepine medications (such as diazepam) can be used to relieve symptoms of agitation and distress, and this may improve tolerance of the treatment.

19. The GMC consent guidelines say doctors can give treatment to a patient in an emergency, without their consent, if that treatment is necessary to save their life or prevent a serious deterioration of their condition.

20. The Trust’s medication policy says how its staff should manage these situations. It says staff can give critical medications covertly when the patient refuses, ‘if the treatment is urgent, there are time constrains, and if it is deemed as appropriate by the registered healthcare professional’.

21. As set out in the background section, Mrs H was not tolerating NIV or HFNO. She was becoming increasingly agitated. Our adviser explained to us that Mrs H needed to receive oxygen. Without it her condition could get worse, and she could die.

22. The doctors had already prescribed diazepam for Mrs H to take if she became agitated. The records show it was part of her normal prescription before she came to hospital. When Mrs H refused to take a diazepam tablet, the Trust covertly gave it by injection in her best interests.

23. Our view is that The Trust’s use of diazepam to relieve Mrs H’s agitation, and increase her tolerance of treatment, was in line with recommendations in the respiratory failure guidelines. The diazepam needed to be given urgently so it was in her best interests, and in line with the relevant clinical standards, to give this by covert injection.

24. We acknowledge Mr H’s concerns that the medication was not suitable because of the side effects. Our adviser explained to us that diazepam does have side effects that can cause slow breathing in some cases. We saw no indications that this should have stopped the Trust from using it.

25. Having considered what should happen and what did happen, we have seen no indications anything went seriously wrong in Mrs H’s care. On this basis we will not consider the complaint further.

26. To offer further reassurance to Mr H, we got information from our adviser which showed that the diazepam was not linked to Mrs H’s death. Our adviser explained that diazepam works fast when injected. Any side effects would be seen within minutes, rather than an hour later. Instead, it appears Mrs H sadly passed away because of the strain on her organs from the respiratory failure.

27. We recognise these issues are very important to Mr H and he has, understandably, been affected by what happened to his mother. We hope our decision and explanation brings him some reassurance and closure.

1. We have carefully considered Mr H’s complaint about the care the Northern Lincolnshire and Goole NHS Foundation Trust (the Trust) provided to his mother, Mrs H, before she died. We thank Mr H for raising his concerns with us and understand how much his loss has affected him and his family.

2. We have seen no indications that anything went seriously wrong in the care the Trust provided to Mrs H. Its decision to give Mrs H diazepam (a medication used to treat anxiety) against her wishes, when she was agitated, was in her best interests and supported by the relevant clinical standards.

3. We recognise Mr H is very concerned about what happened. We hope the explanation of our decision provided in this statement gives him some reassurance about Mrs H’s care.