Appendix 2: Detailed patient case studies

• In 1998, Arthur Cunningham was aged 79. He was a widower who lived in a nursing home.
  
• On 21 July 1998, he was admitted to Mulberry Ward at Gosport War Memorial Hospital, due to renovations at his nursing home.
  
• On 28 August, he was discharged back to his nursing home.
  
• On 21 September, he was reviewed by Dr Althea Lord, a consultant geriatrician, at Dolphin Day Hospital who noted a “large necrotic sacral ulcer which was extremely offensive” and admitted Mr Cunningham directly to Dryad Ward, Gosport War Memorial Hospital, for active treatment of his sore. His nursing home was requested to keep his place open for a period of two to three weeks as he was expected to return there.
  
• On 26 September, Mr Cunningham died.
  

Mr Cunningham was diagnosed with Parkinson’s disease, dementia, reactive depression, diet controlled diabetes and myelodysplasia; he also had an old pelvic injury. Mr Cunningham was experiencing hallucinations and dystonic movements caused by his medication. His mobility was poor and although he could walk he also used a mobility scooter and wheelchair to aid mobilisation. Historically, Mr Cunningham had lived in supported accommodation but by June 1998 he was living in a nursing home and was a regular visitor to Dolphin Day Hospital, Gosport War Memorial Hospital, under the care of Dr Althea Lord.

In June 1998, Mr Cunningham scored 23/29 on a mini mental state examination (MMSE) and was described as well presented and speaking in full sentences. At that time he had expressed dissatisfaction about where he lived, had found it difficult to give up his independence and had refused to return to his accommodation; therefore, new accommodation was arranged at a nursing home.

On 21 July, Mr Cunningham was admitted to Mulberry Ward at Gosport War Memorial Hospital because renovations were taking place at his nursing home. His mental and physical states were assessed on admission and noted on a daily basis. The clinical notes record that he had mild dysarthria, was cooperative and eating independently. He was quiet, with mumbling speech, although his vocabulary appeared normal. He was physically frail with a Parkinson’s tremor in his left arm, some muscle wasting of the left leg and power of 4/5 in both arms. He had some back pain, needed minimal assistance with personal care and was good at transferring himself from bed to chair. He had some urinary incontinence and needed catheterisation. His mood was said to be variable because he was experiencing frustration and unhappiness with his lack of independence; at times, he experienced paranoia and hallucinations.

On 27 August, Dr Lord reviewed Mr Cunningham and noted that his Parkinson’s was a little worse, he was less mobile and there had been a deterioration in renal function; however, he was eating better, had put weight on and his mood had improved. Dr Lord confirmed her view that he should be discharged the next day. On 28 August, Mr Cunningham was discharged to his nursing home. The discharge record noted Mr Cunningham’s creatinine value to be 301.

On 11 September, Mr Cunningham was noted to have settled well into the nursing home.

On 18 September, Mr Cunningham was reviewed by the community psychiatric nurse who noted that he had “settled well into [the nursing home]. There have been no real management or behavioural problems. He can be awkward at times but mostly he is pleasant and compliant. His mood seems good.”

On 21 September, Mr Cunningham was reviewed by Dr Lord at Dolphin Day Hospital. She noted a “large necrotic sacral ulcer which was extremely offensive … his Parkinson’s disease doesn’t seem any worse and he was less depressed but continues to be very frail”. Dr Lord admitted Mr Cunningham directly on to Dryad Ward at Gosport War Memorial Hospital with a detailed note that included plans for active treatment of his sore. His nursing home was requested to keep his place open for a period of two to three weeks as he was expected to return there. Dr Lord noted “prognosis poor”. She prescribed morphine oral solution 2.5–10 milligrams (mg), as required, four hourly, to be administered prior to dressing his sacral sore. Mr Cunningham was administered 5 mg of morphine oral solution at 14:50 and 10 mg at 20:15.

Dr Jane Barton, clinical assistant, also recorded in the clinical notes: “Transfer to Dryad Ward. Make comfortable. Give adequate analgesia. I am happy for nursing staff to confirm death.” Dr Barton prescribed diamorphine 20–200 mg, midazolam 20–80 mg, hyoscine 200–800 micrograms, subcutaneously, as required, over 24 hours. At 23:10, 20 mg of diamorphine and 20 mg of midazolam were initiated and administered by continuous subcutaneous infusion.

The nursing notes record the administration of diamorphine and midazolam and note: “peaceful following”. The nursing care plan records that Mr Cunningham took two glasses of milk while awake.