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.
13. Miss R has concerns about the medication the Trust prescribed to her mother before her death. Specifically, she has concerns the Trust administered a dose of zopiclone that was too high, alongside morphine and midazolam, whilst her mother was oxygen dependent.
14. The Trust says it prescribed Ms F with 7.5mg of zopiclone and it is unlikely this contributed to her death as it was an appropriate dose, given once during her stay.
15. Our adviser has very carefully considered Ms F’s prescription of midazolam, morphine and zopiclone, and if this was clinically appropriate in the circumstances. We will address each of these medications in turn.
16. The anticipatory prescribing guidance says: ‘As a person approaches the last few days of their life, changes in their condition may lead to changes in existing symptoms, the emergence of new symptoms or changes in the person's ability to take medicines to manage their symptoms (such as swallowing oral medicines). Prescribing medicines in anticipation can avoid a lapse in symptom control, which could otherwise cause distress for the person who is dying and those close to them.
17. Midazolam is a sedative and antiepileptic that is considered appropriate to use in palliative care to manage and alleviate any distressing symptoms, like agitation and anxiety. This is also set out in the BNF.
18. The records show Ms F was experiencing periods of anxiety whilst she was in hospital. Ms F had capacity, and anticipatory medications and here wishes were carefully discussed and considered. The Trust’s decision to prescribe midazolam at this time was in line with the anticipatory prescribing guidance, and the BNF.
19. Ms F was also prescribed morphine due to the pain she was experiencing. Morphine is an analgesic, considered appropriate to use in palliative care to manage and alleviate distressing symptoms and pain. This is set out in the anticipatory prescribing guidance and BNF.
20. Marie Curie, an end-of-life charity, also explains about common anticipatory medications that are prescribed towards the end of life. Morphine is listed as a common medication for pain, and midazolam a common medication for anxiety.
21. The records show there were times where Ms F was experiencing pain during her admission. She had asked for pain relief, and reported the morphine helped with her symptoms and pain. It was agreed with Ms F to take steps to keep her comfortable and act in line with her wishes. Our adviser explains it was appropriate and in line with the above guidance to prescribe Ms F with morphine.
22. Regarding zopiclone, organisations such as Marie Cure as well as the BNF advise using zopiclone in end of life if a person is experiencing sleep problems. The insomnia guidance also suggests the use of zopiclone. We understand Miss R has specific concerns about the dose Ms f was given.
23. The insomnia guidance suggests in adults to be prescribed 7.5mg daily at bedtime, which is the dose Ms F was given. We recognise the guidance suggests in some cases a lower dose can be used, and this comes down to the clinician’s judgement.
24. Our adviser explains 7.5mg is the standard dose, and this was reasonable and in line with guidance in the clinical context. As Ms R was under end-of-life care, there was a focus on supporting her distressing symptoms. Ms R had expressed she was having trouble sleeping and agreed to trial this to help her.
25. We recognise Miss R also has further concerns about the combination of the above medications, particularly whilst Ms F was on oxygen. When it was accepted that Ms F was nearing the end of her life, the overriding principle was to manage her symptoms to relieve her from suffering and distress. All medications were prescribed and administered in keeping with this principle.
26. There is no evidence to support these medications bring about end of life sooner. At the time, Ms F had capacity and had expressed to doctors she had experienced pain, anxiety and from 3 March problems sleeping. Our adviser explains the combination of these medications is standard.
27. The evidence suggests Ms F received only one dose of zopiclone on 4 March. Half-life of zopiclone is three and a half to six hours. The half life of a medication is the time it takes for the amount of its active substance in the body to decrease by half. This also supports that it is very unlikely to have had any effective or interaction with other medicines for a prolonged period.
28. We understand Miss R’s significant concerns about these medications before her mother’s death and we are mindful the worry this has caused her so far. These medications are often used when it has been identified someone is towards the end of their life. As a result, this is why patients sometimes die shortly after they have these medications. This is not because they hasten death, but because very sadly the person is already dying, and this has been identified by clinicians. We have very carefully considered the evidence and have seen Ms F’s medications and doses were all appropriate and in line with the above guidance. We hope this can offer Miss R some reassurance and is a helpful explanation.