Appendix 2: Detailed patient case studies

• The records confirm that Dr Logan referred Mrs Devine to a haematologist because he suspected that she might have myeloma. Although myeloma was not detected in the skeletal survey and was not diagnosed, this appears not to have been picked up by a number of clinicians, including the Mental Health Team who variously and wrongly referred to myeloma as part of Mrs Devine’s medical history. During the FtP hearing in 2009, Dr Barton confirmed that “the diagnosis was not, as it turned out, correct … I had taken it from the transfer letter … so it was not myeloma, it was a form of paraproteinemia”.
  
• The acute confusion which led to Mrs Devine’s admission on 9 October, and its subsequent improvement, would be compatible with a diagnosis of delirium. The records indicate that Mrs Devine also had mild dementia.
  
• The Panel notes from the records that Mrs Devine was tested for a UTI and the result was reported as negative.
  
• The Panel notes that there are no records to indicate that at any stage when prescribing or administering morphine oral solution, fentanyl or diamorphine, Mrs Devine’s severe renal impairment was considered.
  
• The Panel notes that Mrs Devine’s renal function had deteriorated but had not been managed. The records do not contain any recent fluid balance chart or any urine output records.
  
• At the time of Mrs Devine’s admission, guidance from the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) and the Royal College of Nursing (RCN) (see Bibliography) emphasised the requirement for nurses to work in an open and cooperative manner with patients and their families. In this regard, the Panel has seen no documents in the clinical records to confirm that nurses engaged in any adequate end of life care discussion with Mrs Devine’s family.
  
• At the time of Mrs Devine’s admission, accountability was an integral part of nursing practice. Nurses were accountable for their actions, and inactions, at all times. The relevant nursing professional codes of conduct and standards required nurses to scrutinise a prescription; question any ambiguity in the prescription; where they believed it necessary, refuse to administer a prescription; and report to an appropriate person or authority any circumstances which could jeopardise the standards of practice or any concern about health services within their employing Health Authority or Trust. The codes and guidance made it clear that to silently tolerate poor standards is to act in a manner contrary to the interests of patients or clients, and contrary to personal professional accountability. The Panel has not seen any document to confirm that nurses treating Mrs Devine challenged the proactive prescription of morphine oral solution, the prescription of fentanyl or the wide dose range in the prescription of diamorphine and midazolam. The Panel has not seen any document to show that nurses consulted the British National Formulary (BNF) guidance or the Wessex guidelines to scrutinise the doses; nor did they question any of the consultants, doctors or the pharmacist at Gosport War Memorial Hospital in respect of the prescription and doses.
  
• The Panel notes that the relevant nursing codes of conduct and standards provided that, when administering or overseeing the administration of drugs, nurses should be able to justify and be accountable for any actions taken.
  
• The Panel has not seen any nursing document in the clinical records to show the reason or rationale for the decision to commence and continue the use of fentanyl, diamorphine and midazolam.
  
• The Panel has not seen any nursing document in the clinical records to show that nurses consulted the BNF guidance, the Wessex guidelines, any doctor or the pharmacist when commencing the administration of fentanyl, diamorphine and midazolam.
  
• The Panel has not seen any document to show that nurses were provided with any written guidance from the doctors, consultants or Portsmouth HealthCare NHS Trust on when to commence the administration of fentanyl, diamorphine and midazolam.
  
• At the time of Mrs Devine’s admission, the UKCC guidance required nurses to carry out a comprehensive assessment of the patient’s nursing requirements, and devise, implement and keep under review care plans. The UKCC guidance also required nurses to create and maintain medical records in order to provide accurate, current, comprehensive and concise information concerning the condition and care of the patient. Such records would include: details of observations, problems, evidence of care required, action taken, intervention by practitioners, patient responses, factors that appeared to affect the patient, the chronology of events, and reasons for any decision. These records would provide a baseline against which improvement or deterioration could be judged. Among other elements of care, “Through their role in drug administration nurses are in an ideal position to monitor the drugs progress, reporting responses and side effects”. In this regard, the Panel found a lack of detail in Mrs Devine’s daily nursing notes. The care plans seen by the Panel were scanty, were not personalised to the patient’s needs and contained missing entries for entire days. For example, between 21 October and 20 November, the ‘Sleep’ care plan contained entries on ten days only. Between 21 October and 13 November, the ‘Bowel Movement’ care plan contained seven entries only. There was nothing that took account of Mrs Devine’s cognitive impairment, capabilities, likes, dislikes and preferences. The Panel found no pain charts or pain management plans in Mrs Devine’s clinical records. It is not clear to the Panel how Mrs Devine’s anticipated pain and the effectiveness of any analgesia was to be adequately monitored. The Panel has found no document which confirms that any assessment of Mrs Devine’s cognitive impairment was carried out or was the subject of a care plan.
  
• The Panel has not seen any fluid charts or nutrition plan among Mrs Devine’s clinical records. Fluid and nutritional intake was an important part of the clinical picture. Fentanyl, diamorphine and midazolam could impair the ability to eat and drink.
  
• In addition to its intended effects, morphine might also have a number of side effects on a patient, including agitation and respiratory depression. The Panel has not seen any document in the clinical records to show that the nurses treating Mrs Devine understood or took into account these possible side effects of morphine when noting Mrs Devine’s condition. In this regard, the relevant nursing codes of conduct and standards required nurses to take every reasonable opportunity to maintain and improve knowledge and competence, including understanding the substances used when treating a patient.
  

In a police statement dated November 2004, Dr Barton said:

In fact, after Mrs Devine’s daughter had received the conclusions of the Independent Panel Review and remained dissatisfied, a member of the Independent Panel produced a further report, which contained the above conclusion. This was not the report of the entire Independent Panel.

• This is an extraordinary conclusion, explicitly condoning the use of large doses of diamorphine simply to control symptoms of confusion and agitation, contrary to all relevant guidance.