Midazolam misshap sees employee find vial in pocket when they return home

Written by Kevin Murphy
19 July, 2023
Midazolam Misshap at care home

In this case study, employment lawyer Kevin Murphy looks at a client case where an employee found a viral of midazolam in her pocket when she returned home


Overview and Background

There were 3 service users who had been prescribed midazolam.  One service user was in the final stages of his end-of-life care and was due a dose of midazolam. The employee in question signed to say that they had administered the dose of midazolam but found the vial in her pocket when she was returned home, having finished her shift.  The employee did not report the error until the next day, instead of ringing the home immediately to allow the service user to be given a dose and arranging for the return and disposal of the dose in her pocket at home.  Unfortunately the service user had passed away that night without the benefit of having been given his dose of midazolam.


Client concerns and aims

Aside from concerns about the passing of the service user, the client was concerned that the employee had not issued the midazolam but had signed to say she had done so.  Albeit that the employee reported the issue the next day, the client was also concerned that she failed to contact the home as soon as she found the medication.

The care home manager undertook an initial investigation and found that the three prescriptions for midazolam had been confused and that several staff members were responsible for the mis-administration of the medication.  The manager was finding it difficult to pinpoint exactly how and where the different prescriptions of midazolam had been mixed up.

The manager had also raised a safe guarding concern.


What we did

1. Assisted with the investigation

We attended the care home to assist with the investigation, we tracked the medication to see which staff had confused the prescribed drugs between service users.  We identified administration errors in relation to counter signatures, recoding deliveries of medications and further administration errors where a service user had not received the medication they should have had. We were also able to identify the members of staff responsible, five in total.

We helped the manager to gather the relevant paperwork and show what each person should have done, find the records that should have been completed and fill in all gaps in the investigation.  We then assisted her to write a statement of what she believed to be the version of events, having investigated the matter.

 2. Guided the disciplinary hearing

We progressed the matter to a disciplinary hearing and advised the Area Manager on what documents to send in advance: providing her with the invitation to disciplinary and a bundle of evidence.

We then provided a question guide for each of the five employees, as each one was slightly different.

3. Provided outcome letters

After the disciplinary hearing, we helped the Area Manager to clarify her thoughts and whether there were substantial grounds to make a finding of misconduct worthy of dismissal.  We assisted her to show why different colleagues and different circumstances warranted different sanctions.



Outcome and benefits

The employer was able to demonstrate to the safeguarding team that the matter was being taken seriously as their HR team adn lawyers were involved. They also knew that the disciplinary meetings were being held properly and that the relevant questions would be asked to help the disciplinary officer arrive at an appropriate outcome.

In the end a range of disciplinary outcomes were given to suit the circumstances of each employee, two were dismissed, the rest who had warnings issued were also provided better training on medication administration.


HR help and advice for your care home group

If you are in the care sector or have carers carrying out home visits and want to ensure you have the right HR support please get in touch with the team who can carry out a free HR review and advice you on your HR headaches.

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