NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Case Study: Safe management of midazolam

A concern was raised by social work over the inability to track a number of doses of midazolam in a patient’s home. The patient has a complex history and is classed as a vulnerable adult. Midazolam is used for treatment of seizures and is a schedule 3 controlled drug (CD). It was previously a schedule 4 CD which has lower restrictions, but controls on use were tightened due to concerns about its potential for misuse, including use as a date rape drug.


The community team were under the impression that the GP practice would only issue prescriptions for midazolam on their request, however a recent check of stock highlighted that a prescription had been generated that the team were unaware of. This prompted a closer review of seizure diaries and GP prescribing pattern.


There were three prescriptions issued by the GP practice over the past two years without the knowledge of the community team. It was not always clear who had collected these prescriptions or whether they were intended for a care service or the patient’s home. Examination of seizure history and discussion with the patient and his main carer was not able to account for the additional prescribed doses. On one occasion, there was the claim that leakage of medicines meant that a full bottle had to be destroyed and replaced and several months later, although six doses should have remained, the main carer was adamant that the bottles were empty and thrown out. This raised a concern that someone was potentially ordering and misappropriating the midazolam.


The local adult protection committee lead was informed, however as there was no evidence of any crime being committed, it was not appropriate for the police to investigate. Clinical review was undertaken which demonstrated no evidence of harm to the patient or anyone else. At the end of the investigation there was no possibility of proving what has happened to the medication and there may have been an entirely innocent explanation.


The focus was then on trying to prevent recurrence. For any drug liable to misuse, practices may wish to consider the following steps:


  • Move midazolam from repeat to acute on the prescribing system. This allows greater control over the issue of any prescription.
  • The GP practice has added notes to the patient’s record to ensure that midazolam is only issued on request from named individuals in the learning disabilities team.
  • The community team have tightened their procedures to ensure there is clear discussion and agreement with patients, carers and GP practices on procedures for ordering medication.