County Durham and Darlington NHS Foundation Trust

3. Miss G complains on 27 September 2021, the Trust inappropriately gave her mother end of life medication (morphine and midazolam) without telling her family. She is also concerned the Trust said her mother agreed to a DNACPR (do not attempt CPR) decision.

4. Miss G believes her mother would still be alive if she had not been given the end of life medication. The bereavement has made her mental health worse and left her feeing broken. She has lost faith in the Trust because she does not believe her mother would have agreed to the DNACPR decision.

5. She would like an independent investigation to provide assurance about the Trust’s actions and acknowledge any failings.

6. Mrs C was an inpatient at the Trust in late September 2021. On 24 September, the Trust completed a DNACPR form. This meant if Mrs C’s heart or breathing stopped, the Trust would not try to restart it.

7. On 27 September, Miss G visited her mother. She recalls a nurse said she would give Mrs C medication to calm her down and within minutes of receiving this, her mother had died.

8. In response to Miss G’s complaint, the Trust said Mrs C had agreed with the DNACPR decision. It also said the medication it gave her included morphine and midazolam. These are anticipatory medications which can be used to manage symptoms occurring at the end of life.

12. Before we decide if we should conduct a detailed investigation of 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. We have done this and have not found any indications that something has gone wrong.

DNACPR

13. The joint guidance on ‘Decisions relating to cardiopulmonary resuscitation’ describes the process for making a DNACPR decision. It says even when CPR has no realistic prospect of success, there must be a presumption in favour of explaining the need and basis for a DNACPR decision to a patient. There should be clear communication and a record of this.

14. The Trust’s DNACPR form refers to Mrs C’s severe COPD and her COVID-19 infection as reasons why CPR would not be appropriate. The records indicate there was a discussion with Mrs C. There is no evidence of a dispute about whether she should be a candidate for CPR. We understand Miss G does not believe her mother agreed with the DNACPR decision.

15. We appreciate Miss G may have had more confidence if the Trust had also discussed the decision with her. Our adviser explained it would have been better practice to have a discussion with Mrs C’s relatives but the guidance does not say this is necessary. As the Trust appears to have acted in line with the relevant guidance, there is no indication of a failing.

Medication

16. The Trust’s complaint response said it gave Mrs C morphine 2.5mg and midazolam 2.5mg at 5.45pm on 27 September for breathing and agitation. We can see an entry from 8.10pm in Mrs C’s records referring to anticipatory medication and Mrs C’s GCS score being 3.

17. The Glasgow Coma Scale is used to measure a person's level of consciousness. A lower GCS score indicates a more severely impaired consciousness, such as a coma. Our adviser explained Mrs C’s score of 3 indicates she was comatose. There is no evidence of her being given morphine and midazolam prior to this.

18. We do not dispute Miss G’s recollection. We note the Trust has been unable to provide a prescription sheet to confirm what it gave Mrs C and when. We considered whether administering morphine and midazolam would have been in line with the relevant guidance.

19. NICE guidance NG31 explains there are some symptoms and changes that happen to people which can be signs that they are close to death. Section 1.5 of the guidance covers the use of medicines to manage symptoms which are common at the end of life, such as pain and breathlessness.

20. The guidance says breathlessness can be managed with an opioid, or a benzodiazepine, or a combination of an opioid and benzodiazepine. These medications work in different ways. Our adviser said it appears the Trust recognised Mrs C was dying. In line with the guidance, it suggested the use of an opioid (morphine) and/or benzodiazepine (midazolam) if needed.

21. Overall, based on the available information, there is no indication of a failing in the care Mrs C received. We know Miss G has questions about what caused her mother’s deterioration. Sadly, Mrs C appears to have had pneumonia and our adviser said it is likely her deterioration was due to the effects of COVID-19.

22. It is clear Miss G has been deeply affected by her bereavement. We would like to offer our condolences for her loss. We hope our investigation reassures her about the care her mother received and it is clear why we have decided not to consider the complaint further.

1. We have carefully considered Miss G’s complaint about the Trust. We recognise she remains concerned about the care her mother, Mrs C, received before she sadly passed away.

2. As we have explained in this statement, we have seen no indication that anything went seriously wrong with Mrs C’s care at the Trust. This is why we have decided not to investigate the complaint further.