23. Before we decide whether 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.
24. We have not seen any indications that something has gone wrong in this complaint. We will explain the reasons for our decision in more detail below.
Medication
25. Mrs U told us she felt as though her mum was being ‘drugged’ whilst she was in the older adults medicine ward as she was always asleep and drowsy. Mrs U said when Mrs O was moved to the Covid-19 ward on 2 October 2022, she seemed completely different in that she was awake a lot more and seemed to be feeling better.
26. Mrs O’s medication record shows 40 medications listed whilst she was on the older adults medicine ward (between 9 August and 2 October 2022). We can see from the records that mirtazapine (a medication used to treat depression) and melatonin (a medication for sleep disturbance) were stopped on 24 August 2022 due to drowsiness.
27. The drug chart in the records shows the Trust was giving Mrs O the medications she was taking at home. This is in line with NICE guidance in relation to preventing delirium. It states ‘carry out a medication review for people taking multiple drugs, taking into account both the type and number of medications. For information on medicines optimisation see the NICE guideline on medicines optimisation [2010]’.
28. The guidance does not focus on continuing medication but on not worsening a patient’s conditions or symptoms. By keeping Mrs O on her regular doses, there was a reduced risk of worsening Mrs O’s delirium.
29. Our adviser told us the Trust gave Mrs O the correct doses of medication and increased them when she was distressed. An example of this is that the Trust was giving Mrs O diazepam (a medication which slows down the nervous system) for anxiety. This was on an ‘as and when needed’ basis, to be taken a maximum of once a day. It was giving this medication in the lowest possible dose for the shortest amount of time.
30. The BNF guidance on hypnotics and anxiolytics supports the approach. It states ‘Most anxiolytics (‘sedatives’) will induce sleep when given at night and most hypnotics will sedate when given during the day. Prescribing of these drugs is widespread but dependence (both physical and psychological) and tolerance occur. This may lead to difficulty in withdrawing the drug after the patient has been taking it regularly for more than a few weeks. Hypnotics and anxiolytics should therefore be reserved for short courses to alleviate acute conditions after causal factors have been established’.
31. The records show the doses were increased from 16 August to 22 August to maximum twice a day as required due to concerns about her levels of anxiety. Mrs O only had two doses on 17 August and 21 August.
32. Within the NICE guidance on delirium, the section entitled ‘treating delirium’ states a short term dose of haloperidol should be given if a person is distressed or considered to be a risk to themselves or others.
33. Our adviser told us that although haloperidol is recommended, she was already taking diazepam, so continuing to use diazepam would have been in line with the BNF guidance on hypnotics and anxiolytics.
34. The ‘BGS comprehensive geriatric assessment: medication and history review’ (CGA) does not give an exact time frame focus on reducing drugs with an anticholinergic burden on admission. It states careful consideration and discussion with individuals is essential to ensure that medication is tailored to focus on maintaining health whilst enhancing quality of life in a way that aligns with individual patient priorities.
35. The NICE guidance on benzodiazepine and z-drug withdrawal generally recommends initiating them again when the patient is back in primary care.
36. We can see there is no dispute that Mrs O did have periods of heightened distress. Mrs O’s family agrees with this and therefore increasing the doses at these points was also in line with Mrs O and her family’s wishes.
37. In terms of the amount of medications Mrs O was prescribed and/or taking, Mrs O will have acquired medication from each medical professional she had seen throughout her care.
38. Our adviser told us it is likely that nobody had looked to reduce the medication. It was not the right time to review this during the period of care we are considering, as she was receiving acute care at that point. The recommendation in the CGA is that medical professionals should wait until the patient is in the recovery stage to reduce then withdraw some of the medications.
39. The NICE guidance on delirium states ‘hypoactive delirium can present with lethargy and reduced concentration and appetite’. Our adviser explained it is therefore more likely that Mrs O’s hypoactive delirium caused the drowsiness as opposed to being give too much medication.
40. We can understand why Mrs U would question Mrs O’s drowsiness. We know this will have been upsetting to see.
41. We have carefully reviewed Mrs O’s medical records and have not seen evidence the Trust was giving Mrs O too much medication. As she was receiving acute care, it was not right to change the medications and the focus was on treating her acute symptoms.
42. We recognise Mrs O was taking a lot of medications, but the treatment was in line with guidance, based on her condition. This means we have not seen that anything went wrong.
Dementia treatment/diagnosis
43. Mrs U told us she has a strained relationship with her stepsister. She said her stepsister told the Trust Mrs O had dementia so she would receive better care. She said Ms O was never formally diagnosed with dementia but doctors relied on what her stepsister told them. She said she does not know which organisation diagnosed Mrs O with dementia but she saw some mentions of it in GP notes between 2020 and 2022. She says Mrs O was given wrong medication and treatment due to this.
44. We can see Mrs O’s GP queried dementia in the community and this was on her record. The Trust told us in its email dated 2 April 2025 that Mrs O was treated as having dementia based on information recorded in the GP summary care record and her clinical presentation at the time, which shows it interpreted the information in her records as a diagnosis. We reviewed the records and could not see any active treatment for dementia.
45. Our adviser told us there is no specific medication for vascular dementia and there is only medication for the symptoms that arise from it. Mrs O was therefore not receiving specific treatment for dementia.
46. She was taking three main medications: melatonin to help improve her sleep cycle, a long term prescription of Benzodiazepine (diazepam) and Mirtazapine (an antidepressant). These were used to manage Mrs O’s symptoms of delirium.
47. As mentioned above, these medications were appropriate as they were medications she was already taking before her admission. The Trust did not add any medications excessively or withdraw any she should have had.
48. On 9 August 2022, the day Mrs O was admitted, she had blood tests which showed an elevated CRP (C-reactive protein) and white blood cell count, which suggested she had an infection. Our adviser said the infection caused the delirium and this was treated appropriately with antibiotics and hydration. This is in line with NICE guidance on ‘preventing delirium’ which states:
‘1.4.5 Address dehydration and/or constipation by: • ensuring adequate fluid intake to prevent dehydration by encouraging the person to drink; consider offering subcutaneous or intravenous fluids if necessary • taking advice if necessary, when managing fluid balance in people with comorbidities (for example, heart failure or chronic kidney disease). [2010]
1.4.6 Assess for hypoxia and optimise oxygen saturation if necessary, as clinically appropriate.Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes. [2010]
1.4.7 Address infection by: • looking for and treating infection • avoiding unnecessary catheterisation • implementing infection control procedures in line with the NICE guideline on healthcare-associated infections. [2010]’
49. Our adviser explained delirium can present similarly to dementia. He mentioned it being superimposed delirium which is when delirium occurs concurrently with preexisting dementia.
50. It is clear Mrs O had delirium because when the infection was treated, her delirium symptoms improved. If Mrs O only had dementia, then treating the infection would not have improved the dementia. Therefore, it was most likely delirium and not dementia that caused Mrs O’s symptoms. The medications were used appropriately as they improved her symptoms.
51. We recognise that there is a grey area in terms of when dementia was diagnosed, but Mrs O’s treatment was in line with standards and guidance. As explained, it was her symptoms that were bring treated throughout her admission and this was in line with guidance. We therefore see no indications of a failing here.
52. We are very sorry to hear about how distressing this time was for Mrs U and her family. We understand why Mrs U was worried about Mrs O’s drowsiness and that she may have been receiving incorrect treatment. We hope our decision provides Mrs U with assurance about what happened with Mrs O’s care.