Choice of medication
10.In the context of this complaint V’s medical records show that he was prescribed the following medication.
• Lorazepam (regular intramuscular 0.5mg three times a day) was commenced on 30 September 2020 and discontinued on 5 October.
• Lorazepam (as required intramuscular 0.5mg) was commenced on 30 September 2020 and discontinued on 3 November.
• Lorazepam (regular oral 0.25mg twice a day) was commenced on 16 October 2020 and discontinued on 30 October.
• Quetiapine (regular oral 12.5mg twice daily) was commenced on 30 October 2020 and continued until discharge on 3 November. It was included on the discharge medication list to be reviewed by Mr Barnes’ GP.
11.We think the use of both medications was appropriate, in line with the relevant guidance, and necessary to help manage V’s symptoms. We do not agree with Mrs C’s view that the medication used was ‘too strong’ for V. We do believe there was any other, less strong, medication that could have been used instead that would have worked just as well.
12.His records show that V was at times ‘aggressive/agitated’, including being violent to staff on 29 October 2020. Where patients are agitated, it is standard practice to give them something to calm them down and to try to help them with their agitation. SIGN 157 guidance (below) refers to the use of drugs like lorazepam and quetiapine in this context. This guidance shows that the Trust acted reasonably in this case.
• See algorithm at Annex 4 p47, the box ‘Treatment of Delirium Symptoms) medication for management of unmanageable agitation/distress include ‘atypical antipsychotics (of which quetiapine is one) and lorazepam (at a dose of 0.5-1mg to a maximum of 2mg/24hours).
13.Our adviser explained that quetiapine can be, and often is, used in cases of delirium and that it has been found to be a safe choice in that context, as explained in the following published guidance (Quetiapine for the treatment of delirium (mdedge.com). Also, quetiapine is thought to reduce the duration of delirium and therefore to be of benefit to the patient (SIGN157 - section 7.1 on p25).
14.On that basis, we think the choice of medication was reasonable. It was in line with published guidance. It was also in line with standard practice, meaning V was likely to have received similar care wherever he had been treated. The medication used was known to be beneficial in cases like V’s and it was chosen by the Trust for that reason, to try to help him.
Doses of medication
15.Our adviser explained that when quetiapine is used for the treatment of delirium, the usual dose often starts at 25mg once daily increasing in steps up to 175mg in divided doses. This demonstrates that the dose used for V (12.5mg twice daily) was a very low dose and, we think, appropriate in his case. The dose of lorazepam V was given was also low (0.25mg twice a day) when compared to SIGN guidelines suggesting 0.5-1mg up to 2mg in 24 hours (see above). This is the same starting dose recommended by the relevant NICE guidance (Delirium: Lorazepam).
16.On that basis, we think the doses of medication given to V were appropriate, sensible in the circumstances, and in line with the relevant guidance.
17.V asked whether some other, less powerful medication have been used instead, something less strong that would have worked just as well. We do understand her concern, as it is never a good idea to give patients stronger medication than they need. However, we do not believe there was nothing ‘less strong’ that the Trust could have used ‘that would have worked just as well’ in this case.
18.Our adviser explained that, overall, there is no clear evidence that any one antipsychotic medication is better than another for use in delirium. It often depends on which side effects are more tolerable and which are more dangerous. For example, haloperidol is another antipsychotic often used in delirium but it and other first-generation (i.e. older) antipsychotics increase the chances of seizures happening (Antipsychotic Medications – see line 5 of the section headed ‘Adverse Effects’) and V was known to have epilepsy.
19.On the other hand, benzodiazepines (a group of drugs of which lorazepam is one) are associated with falls in the elderly (Benzodiazepines and falls), so it would only be used in the short term while in hospital.
20.There are differences the side effects various drugs can have (Adverse Effects of Antipsychotics - see table 3) but overall quetiapine is one of the lower side effect antipsychotics and so we concluded it was an appropriate choice in V’s case.
Did the use of quetiapine contribute to V’s death?
21.As explained above, we think the use of quetiapine was reasonable while V was in hospital for the period covered by this complaint. Subsequently, his GP discontinued the quetiapine on 11 November 2020. It was restarted very briefly when V was readmitted in mid-November but was discontinued on the same day. Similarly, it was restarted when he was readmitted at the end of December, but only briefly. Instead, risperidone was commenced on 23 December 2020 at 0.5mg twice daily and this was reduced to 0.25mg once a day in the evening – a very low dose compared to usual doses used in the elderly (BNF risperidone).
22.So, overall the doses and durations of treatment (with quetiapine) were low and quite short. Also, we noted that drugs like quetiapine (second-generation antipsychotics, of which quetiapine is one) have not been shown in any studies to be associated with increased mortality/death in patients (Antipsychotics and mortality).
23.In summary, we do think V was given any inappropriate medication. In simple terms, he was given the right drugs, at the right time, in the right amounts. We hope Mrs C will be reassured by our view that the use of quetiapine did not cause, or contribute to, her husband’s death.