Midazolam 15. Mr R complains that the Trust gave his mother incorrect doses of medication. He says that the Trust should not have given her this medication as it is a respiratory depressant, and he is concerned it caused his mother’s condition to deteriorate in hospital.
16. Ms R was given Midazolam medication to help her to tolerate the CPAP treatment she was receiving for her Covid-19 symptoms. Our adviser has explained that there was no national guidance for the use of Midazolam as an aid to tolerate CPAP therapy during the Covid-19 pandemic. However, BNF guidance does say sedation may be used to help patients tolerate non-invasive ventilation, such as CPAP therapy, as it can be a very uncomfortable treatment to tolerate. Midazolam was therefore being used for this. The Trust’s palliative care guidelines for Covid-19 patients suggested a maximum midazolam dose of up to 60mg daily.
17. Ms R’s medical records show that she was initially given Midazolam on 14 August to help her tolerate the CPAP machine. The records note she was given continuous doses because she needed this non-invasive ventilation, and the records note she was tolerating CPAP therapy with the aid of this sedative medication. Midazolam was continued to help with her toleration of this and to provide relief and relaxation. This is in line with the guidelines above. Ms R was given 20mg daily. This dose is in line with the palliative care guidelines for Covid-19 patients above. The Trust acted in line with the guidelines when giving Ms R this medication.
18. Sadly, Ms R’s condition deteriorated in hospital from 14 August despite the Trust providing CPAP treatment to manage her symptoms. Our adviser explained that by 14 August Ms R was receiving the maximum flow rate that can be given to a patient and her oxygen levels remained abnormal despite this.
19. We empathise with Mr R, but the records do not indicate that his mother’s deterioration was caused by the doses of Midazolam the Trust were giving her. Based on the evidence we have seen, we are satisfied that Midazolam was being used throughout Ms R’s admission to help her through CPAP therapy in line with the guidelines.
DNAR 20. Mr R says the Trust made the decision to put a DNAR order in place without proper discussion with his mother and family.
21. Joint guidance from the BMA, RCUK and RCN says if a DNAR decision is made on clear clinical grounds that resuscitation would not be successful, clinicians should discuss this with the patient and explain the reason for it. The guidance also says that those close to the patient should also be informed and offered an explanation, unless a patient’s wish for confidentiality prevents this.
22. Ms R’s medical records show that the respiratory consultant discussed the decision to put a DNAR in place with her on 14 August. They also note that a further discussion took place with Ms R’s partner on 16 August as it was documented that Ms R had agreed they could be informed. The records detail that the respiratory consultant explained that Ms R’s condition indicated that resuscitation would not be successful.
23. The notes in the medical records indicate that the Trust followed the above guidelines by discussing the DNAR decision Ms R and her partner and it explained the basis for this decision. Although Mr R is concerned this did not happen, the detailed records of these discussions in the notes indicates that it did. We therefore cannot say that the Trust got this wrong.
24. Based on the evidence we have seen, the Trust followed the correct guidelines in putting the DNAR decision in place and explaining this decision to Ms R and her partner. We can understand Mr R’s upset and distress regarding this decision and his worry that it was not discussed properly with his mother. We hope our explanations above give him some reassurances that this does not appear to have been the case.
End-of-life-care 25. Mr R says the Trust incorrectly placed his mother on end-of-life care and did not make her a candidate for intensive care.
26. ICS guidance says that when clinicians assess whether Covid-19 patients will benefit from critical care, there are three areas to consider: age, clinical frailty and co-morbidity.
27. Ms R had a clinical care review on 14 August, when the Trust gave her a clinical frailty score of six. The Trust documented she could only walk short distances and needed a stairlift at home. It also noted that she suffered from chronic obstructive pulmonary disease (COPD).
28. Our adviser explained that these indications meant that although Ms R was 55 years old, her clinical frailty and pre-existing co-morbidity meant that her chances of surviving an intensive care admission were low. Our adviser explained that the Trust carried out its assessment of Ms R’s condition in line with the above guidance and based on the critical care review, Ms R would not have benefitted from intensive care intervention.
29. NICE guidance says in caring for patients in the last days of life, hospital staff should assess what medicines a patient may require managing their symptoms likely to occur, such as agitation, breathlessness and pain. The guidance also says staff should consider managing breathlessness with an opioid or a benzodiazepine.
30. The records do not indicate that Ms R was formally placed on end-of-life care. However, the Trust first sought advice from its specialist palliative care team on 18 August. It advised that she be given oxycodone (an opioid drug) to help manage her breathlessness and to seek further advice if required.
31. The palliative care team reviewed Ms R again on 20 August and noted she was tolerating CPAP therapy with medication, but her prognosis remained uncertain. The Trust prescribed anticipatory medication in the event of further deterioration. This means she had a prescription for medication to manage her symptoms if and when she deteriorated to manage her symptoms. This is in line with NICE guidelines as the Trust assessed what medicines Ms R may need to manage her symptoms that were likely to occur during the last days of life.
32. On 23 August the Trust noted that Ms R had sadly deteriorated further on the weekend, and it gave her sedatives through a syringe driver, which is a small infusion pump used to gradually administer small amounts of fluid to a patient, to ensure she was comfortable and manage her breathlessness. This is in line with NICE guidance, which recommends the use of sedative medication to manage the discomfort caused by a patient’s breathlessness.
33. Based on what we have seen, the Trust acted in line with the relevant guidelines in not offering intensive care intervention to Ms R based on its assessment of her clinical frailty and pre-existing COPD. The records show that although Ms R was not formally placed on end-of-life care, her symptoms of pain and breathlessness were managed in the last days of her life in line with the above guidelines.
34. We hope that our explanations have given Mr R some reassurances about what happened.
35. Having carefully considered the evidence we have seen, we have seen no indication that something went wrong with the care Ms R received from the Trust and have therefore we do not uphold Mr R’s complaint.
36. We know our investigation cannot change what happened to Ms R or take away Mr R’s pain. We sincerely hope our decision addresses the concerns Mr R has about what happened and provides some reassurance around the care his mother received.