An inquest into the death of a man whose family believe was unlawfully killed by the inappropriate administering of end-of-life drugs, including the sedative midazolam, has begun hearing evidence.
The Inner London Coroner’s Court last week heard five days of testimony from medical staff involved in the care of Derek Dimmock, 86, who was agitated and in pain thought to be caused by gout, when he was taken to the Royal Trinity Hospice (RTH) in Clapham on June 6, 2020.
Within three hours of admission, he was put on a syringe driver containing midazolam, the opioid oxycodone, and alfentanil—a fentanyl derivative which gives short-term pain relief—after doctors assessed that he was “in the process of dying.”
The hospice report said he “just ran out of breath,” but his wife Maureen Dimmock stated that he declined rapidly from being “fully alert” in the ambulance to comatose after the syringe driver was started.
Although Dimmock, who lived in Putney, suffered from a complex range of age-related health conditions, his wife said he did not appear on the verge of death when he was taken to the hospice, a view supported by the evidence of the crew who transported him in a non-emergency ambulance and by a nurse who saw him the day before his admission.
Accusations of Bias
The past week of evidence revealed several points of contention between the family and medical staff, with the Dimmocks’ son Paul accusing the coroner of showing biased treatment to the hospice’s counsel, Amanda Wright-Kluger, KC, leading to a two hour break in proceedings.
The coroner Dr. Julian Morris, who is qualified as both a lawyer and a doctor, will determine whether the death was a “natural” one, or whether it amounted to unlawful killing, as the family believes.
Former porter Dimmock, known as Del, had previously stayed at RTH in Clapham for respite care in January to February 2020, recovering well enough to be discharged. He had expressed a wish not to go to hospital again after a number of stays related to heart and kidney failure, and had preferred his time in the hospice.
He was usually cared for by his wife with the help of community nurses, and had an informal diagnosis of dementia, which had begun to impact his behaviour. He had been diagnosed with anaemia and gout—a form of inflammatory arthritis—and had recovered from skin cancer.
Two palliative care medics at the hospice, consultant Dr. Amy Kingston and registrar Dr. Phoebe Wright, said that Dimmock’s GP, Dr. Fhorkan Uddin, had told them that Dimmock’s wife and son thought he was “beginning to die.”
‘Anticipatory Medications’
The court was told that Uddin, who did not appear as a witness owing to being on long-term sick leave, had prescribed midazolam for Dimmock without doing his own assessment after community nurse Anne Wheeler recommended “anticipatory medications” because she assessed that he was deteriorating.Appearing in place of his practice partner Uddin, GP Dr. Owen Evans, who was retiring on the day he gave evidence, could not explain why Uddin had not wanted to carry out his own assessment.
Nurse Wheeler said there was no plan to “sedate” Dimmock, but the package of medicines was requested on June 5. in case he deteriorated further over the weekend, and that the 10 ampules of midazolam ordered was nothing unusual, as it was common practice to request more than would be used.
Community nurse Rosie Ellwood, now retired, also saw Dimmock on June 5, and told the court he did not appear to be about to die, and recalled that he was able to swallow when she gave him a cup of tea. But because he couldn’t always swallow and was having his painkillers crushed, Wheeler said she ordered injectable forms of all his medications.
Paramedics found him conscious when they arrived to take him to the hospice the following day after his pain and distress worsened, and said he responded well to nitrous oxide for pain relief.
Maureen Dimmock said it became clear to her that her husband was being deprived of fluids as he was not given a drink in her sight, and she did not believe a swallow test was carried out.
She said that retrospectively, it was clear that “some kind of automatic protocol or formula was being used” to shorten or end her husband’s life, which staff had stuck to “like robots” and was “the most shocking thing I have ever experienced ... callous, cold, and cruel.”
Nurse Nancy Griffin-Gauldy said that while it said “nil by mouth” on Dimmock’s record, it was not the case that he was being deliberately deprived of food and fluid, and she “would have tried to give him a drink” as part of her normal practice, but could not recall events exactly from five years ago.
Asked by Bogle whether she felt it was “a little premature” to start the syringe driver after only one injection of midazolam, Griffin-Gauldy replied: “I was a band five nurse, and I know more now than I did then. I wasn’t thinking at the time that we should do another PRN [dose as needed] or start at a lower dose ... I wasn’t thinking that at the time.”
‘Progressive but Fluctuating’
Kingston, who was ultimately responsible for his care, said that Dimmock was brought to see what the reason for his deterioration was, and if anything could be done to reverse it. She said he had a “progressive but fluctuating” condition, and organ failure could make the journey to death especially “unpredictable.”“People die in different ways ... people can deteriorate gradually or die suddenly,” she added.
Dr. Phoebe Wright, who was on duty when Dimmock arrived, told the court he was first given an injection of midazolam to help with his agitation and in the hope of relaxing his muscles to he could be moved more easily.
When he began to deteriorate, she said the decision was made to set up the syringe driver after discussion with Kingston.
Wright said that Paul Dimmock had raised concerns that “the dying process was being speeded up by the drug cocktail and use of the syringe driver,” and that she had sought to reassure him that this was being done to allow his father “to be dignified.” He was also concerned that COVID-19 might wrongly be put on the death certificate, but Wright said this wasn’t a consideration and they hadn’t even tested his father for the virus.
Speaking from Hong Kong where she is on sabbatical, Wright said Dimmock was not given fluids artificially because he was initially too “agitated” to cannulate and it was decided to wait and see if he could take a drink.
By the following day, June 7, Dimmock appeared to be “actively dying,” Wright said. When asked why he still wasn’t given fluid when he became comatose, Wright said it was “unclear whether giving fluids to actively dying people makes their symptoms worse or better.”
The nurse who was on duty when Dimmock died, Patricia Bateson, said she “noticed a change in his breathing” and called his wife to enable her to be with him at the end.
Questioned on whether the syringe driver had been helping Dimmock or hastening his death, Bateson said she always approaches giving medication “with a questioning mind.”
“I don’t just go and get it and give it,” she told Bogle, adding, “I’m not careless with drugs.”
NHS Protocol NG163
The inquest follows pressure from the Dimmocks, who are among a group of bereaved relatives who say their loved ones were unlawfully killed after being placed on the National Institute for Clinical Excellence (NICE) protocol NG163, which involved giving midazolam and opioids as end-of-life care rather than trying any other treatment.Some of those involved say their loved ones had COVID-19 wrongly put down as the cause of death, and have suspicions this was used to inflate the death toll from the illness.
In April 2020, four weeks into the first lockdown, then-Health Secretary Matt Hancock discussed the procurement and use of midazolam with his fellow Conservative MP, former GP Dr. Luke Evans, in a video session of Parliament.
Hancock ordered a two-year supply of the drug, and it was prescribed at a significantly higher rate than usual during the lockdown era. A member of the benzodiazepine family, midazolam is used in anaesthesia as well as for sedation, and is the drug of choice for the execution of U.S. death row prisoners.
Speaking at the August 2023 criminal trial of a man found guilty of harassing him, Hancock dismissed accusations that euthanasia was used during lockdown in order to inflate the COVID-19 death toll as “a false conspiracy theory spread on the internet by people who don’t believe that a vaccine should be taken, so-called anti-vaxxers.”
April and May 2020 saw a huge spike in care home deaths, many of which were attributed to COVID-19, while visits to care homes and hospitals were not allowed. “Do Not Resuscitate” orders were routinely put on the medical files of the elderly, the disabled, and those with serious illnesses during this time, with the Scottish COVID-19 Inquiry hearing hours of testimony from those affected, as well as from witnesses who believe their loved ones were euthanised.
Whistleblowing care workers have supported claims that the elderly and vulnerable were remotely prescribed end-of-life drugs by their GPs, and were in some cases deprived of food, water, and their usual medications.
Concerns Raised in Parliament
The former Conservative MP Andrew Bridgen raised concerns about the misuse of midazolam for COVID-19 patients during a parliamentary debate on excess deaths in April 2024, questioning why the updated guideline to NG163, known as NG191, had been removed from the NICE website.Bridgen asked: “If legal cases for unlawful killing are brought, can the minister tell us who is going to be taking the blame? Will it be NICE, will it be NHS England, or will the individual doctors and nurses be held to account?”
While an inquest is not a trial, if a conclusion of unlawful killing is reached, then criminal or civil proceedings may follow separately. A coroner also has the power to make a Preventing Future Deaths report, which could result in new guidance being issued, such as around the prescribing of end-of-life drugs.
The coroner agreed that evidence relating to the banned Liverpool Care Pathway could be submitted as part of the Dimmock family’s evidence, despite objections from Wright-Kruger, who argued it was not relevant.
The palliative pathway, designed for terminally ill cancer patients, came under fierce criticism for being used inappropriately and without consent, with instances of it being used to starve people to death, before it was phased out in 2014.
The inquest is expected to conclude after Easter, and will hear evidence from medical experts on behalf of the Dimmock family before the coroner delivers his conclusions.
