12. Ms D told us DISS prescribed anti-psychotic and sedative drugs (lorazepam, zopiclone and risperidone) which were inappropriate for her father’s condition, to sedate him and remove his one-to-one care and did not consult his family first.
13. She told us her father has permanently lost the use of his legs due to muscle deterioration. We do not underestimate how frightening and difficult this must have been for Mr and Ms D. This also happened during the COVID-19 pandemic when social visits were not allowed.
14. The Trust says Mr D had already been prescribed lorazepam when DISS took over the care. Mr D’s GP prescribed risperidone in November 2020 and zopiclone PRN (as and when needed) on 4 February 2021 to help with Mr D’s erratic sleep patterns.
Lorazepam and risperidone
15. Our policy lists circumstances where we may not be able to investigate a complaint in further detail. This includes if an investigation would not be practical or it would not reach a satisfactory conclusion.
16. We think an investigation into Ms D’s complaint about lorazepam and risperidone would not be practical. This is because we are unable to find the evidence needed to make a robust decision and because the issue complained about involves an organisation we have not been asked to investigate.
17. Firstly, we cannot say exactly what medication was given to Mr D and when. This is because we are unable to gain access to Mr D’s medication charts. Another organisation confirmed the charts are in paper form and they are unable to provide them.
18. We asked the Trust for Mr D’s medical records, including records of prescribed medications. Unfortunately, the records do not include medication charts. This is because Mr D lived in a care home and medication is recorded at the point at which it is given by care home staff.
19. We considered whether we had enough information to make a decision from the information the Trust gave in its complaint response to Ms D about the lorazepam and risperidone Mr D was prescribed and administered. We do not have enough information to investigate because we do not have access to the original records to see when he was given his prescribed medication.
20. Secondly, the actions of the DISS are closely linked with the prescribing decisions made by clinicians at other organisations.
21. We can see another organisation started the prescription of lorazepam. We understand the GP prescribed risperidone to Mr D.
22. Ms D told us she does not want to complain about the actions of the GP, the care home or any other organisation because she thinks Mr D’s care and treatment was the sole responsibility of the DISS.
23. We appreciate the efforts Ms D made to bring her complaint to us and recognise the importance of it to her. We understand this outcome may be disappointing for Ms D and are sorry we have been unable to investigate this part of her complaint.
Zopiclone
24. NICE guidance on zopiclone says when prescribing to the elderly, clinicians should prescribe ‘Initially 3.75 mg once daily for up to 4 weeks, dose to be taken at bedtime, dose may be increased if necessary to 7.5 mg once daily.’
25. With guidance from its own community mental health team, DISS prescribed zopiclone PRN on 4 February 2021 to help with Mr D’s erratic sleep patterns.
26. We got advice on whether it was appropriate for DISS to prescribe zopiclone to Mr D, and if so, whether the dose was correct.
27. Our adviser told us it was appropriate for zopiclone to be given to Mr D. They explained there is no contraindication to prescribing of zopiclone in Parkinson’s dementia (meaning it will not cause harm when taken).
28. Zopiclone is licenced for insomnia (up to four weeks) with a usual older adult dose of 3.75mg. We can see Mr D was prescribed zopiclone at doses of 3.75mg.
29. Our adviser told us although this was prescribed for longer than the ‘short-term’ licence, this is not particularly unusual. Off licence prescribing is justifiable as long as a risk versus benefits assessment with associated reviews is done and, in this case, Mr D was having DISS reviews.
30. In summary, we can see no evidence that DISS did not follow guidance when it prescribed zopiclone and the dosage and monitoring was in line with NICE guidance.
Communication with Ms D about prescribing
31. NICE guidance says, ‘involve the person’s family members or carers (as appropriate) in support and decision making’.
32. Ms D told us DISS did not communicate with her before Mr D was prescribed zopiclone. She says if she was told, she could have told DISS it was not appropriate and the prescription could have been stopped.
33. We recognise how frightening it must have been for Ms D when she found out later her father had been given zopiclone, which she thought was not appropriate for him.
34. The Trust says it would like to reassure Ms D that staff always try to work closely with patients, carers and families as it knows their involvement plays a crucial role in the recovery of the patient.
35. It has learnt from Ms D’s complaint, including the need to improve communication between staff and relatives. It says it has taken this learning forward and put measures in place to stop a repeat of similar concerns.
36. It says it will work to improve its communication with relatives, as many of the issues Ms D raised could have been dealt with if there had been more effective and open communication.
37. Mr D’s medical records show that on 30 November 2020 a clinician stated, ‘Capacity: [deprivation of Liberty] (DOL)’s in place. Daughter has [power of attorney] for finances and property’.
38. Information provided by the Social Care institute for Excellence says a ‘DOL ensures people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty. Arrangements are assessed to check they are necessary and, in the person’s, best interests’.
39. The record on 29 March 2021 states, ‘Even though she did not have power of attorney [POA] in terms of health and welfare of Mr [D], I thought it was prudent to alleviate her anxieties by answering her questions… I reassured her that in the future in so far as the lack of power of attorney for health and welfare allows, we will keep her up to date. I also explained to her that Mr [D] has now been discharged from the DISS Team’.
40. We got advice on this part of Ms D’s complaint.
41. Our adviser explained it seems that Ms D had property and finances POA but not a health and welfare POA. This means there is no legal obligation to consult with Ms D about health matters or for medications to be approved by her.
42. They explained Mr D was under a Deprivation of Liberty Safeguards (DoLS) legislation (which is part of the Mental Capacity Act). The prescribing of his medication would be part of a care plan using least restrictive practice and the patient’s best interests.
43. They told us best practice would involve including family members/carers in the care plan, as that consultation may better allow understanding of what is in the patient’s best interests.
44. We recognise Ms D feels angry that she was not consulted before her father was given zopiclone.
45. As Ms D did not have power of attorney for health and welfare and Mr D had a DOLS in place, if a discussion had taken place we cannot say if this would have changed the decision to prescribe zopiclone.
46. We can see from NICE best practice guidelines that Ms D should have been included in discussions about her father’s care and this did not happen. But, given the lack of POA for health and welfare, there was no legal obligation for this to happen and we are unable to say if this would have changed the outcome.
47. As explained above, we can see the decision to prescribe Mr D zopiclone was correct.
48. The Trust acknowledged Ms D did not have POA on health and welfare, but it is noted that staff were keen to reduce her anxieties by answering her questions and as so far as the lack of POA allowed, they kept her updated.
49. We can see the Trust made a decision in the best interests of Mr D, given he had a DOLS in place.
50. We do not think the actions of the Trust fell so far short to be a sign of a failing. We will not take any further action.
51. We recognise how difficult it has been for Ms D and Mr D. We hope we have explained the reasons for our decision clearly.