Decision Report 201609310

Summary

Ms C's mother (Mrs A) had a number of health concerns and she required numerous hospital admissions over the course of two years. Ms C complained about the removal of diazepam (a medication used to treat anxiety) from her mother's medication regime during one of her admissions. Mrs A had been taking diazepam regularly for over forty years, and Ms C believed that its sudden withdrawal had caused delirium, which led to a worsening of Mrs A's dementia and her eventually having to go into a care home.

The board did not consider that Mrs A's increased confusion was necessarily caused by the withdrawal of diazepam. They noted that there were a number of other possible causes, including several long-term conditions and other issues, including acute infections. They accepted, however, that there had been some shortcomings when recording medicines on admission and on discharge and they identified this as a learning point.

We took independent advice from a consultant in acute medicine. We found that there are often multiple potential causes for delirium, and the adviser thought it unlikely that Mrs A's decline was attributable to diazepam withdrawal. We noted that there appeared to be admissions during which Mrs A was not administered any diazepam and showed no signs of withdrawal. Given that Mrs A was on a relatively low dose, the adviser did not think the withdrawal had caused Mrs A's delirium and decline. We therefore did not uphold this complaint.

Ms C also complained that the board failed to ensure that her mother was receiving reasonable medication therapy following the decision to stop her diazepam medication. The board had found during review that an alternative was prescribed and administered, albeit inconsistently. We found that Mrs A was on other medications which may have alleviated the need for a substitute and we noted that Mrs A had managed for several days during one admission without diazepam and without any signs of withdrawal. The adviser therefore thought it reasonable to have stopped this medication, assuming that withdrawal would not occur. We found that, at a later date, a susbtitute was introduced to Mrs A's medication regime, and the adviser did not consider that this was needed before this point. Therefore, we did not uphold this complaint.