Appendix 2: Detailed patient case studies
Case Study – Gladys Richards
Summary of hospital admission
- In 1998, Gladys Richards was aged 91 and was resident in a nursing home.
- On 29 July, she fell and fractured her right neck of femur. She was admitted to the Royal Hospital Haslar (‘Haslar Hospital’), where she underwent a right cemented hemiarthroplasty (partial hip replacement).
- On 11 August, she was admitted to Gosport War Memorial Hospital for rehabilitation.
- On 13 August, she fell at Gosport War Memorial Hospital and dislocated her right hip.
- On 14 August, she was transferred to Haslar Hospital where the dislocation was treated.
- On 17 August, she returned to Gosport War Memorial Hospital.
- On 21 August, Mrs Richards died.
Background, care and treatment
On 4 February 1998, Mrs Richards was assessed by Dr Victoria Banks, a psychiatrist specialising in old age. Dr Banks confirmed that Mrs Richards was “cognitively … obviously severely impaired”. However, she was not found to be depressed. Dr Banks’s view was that Mrs Richards had “severe dementia with end stage illness”. She prescribed a regimen of haloperidol, trazodone and lavender oil, with the possibility of utilising other drugs in the future. By May 1998, Mrs Richards was described by staff at the nursing home as “withdrawn and anxious at times” but as being settled most of the time due to her new drug regimen. Mrs Richards wore pads for incontinence, required help with washing and dressing and also needed encouragement and help to eat. She would usually sleep through the night but would get up and wander at times. Mrs Richards’ daughters and granddaughter were heavily involved in her day-to-day care and would visit her at the nursing home daily. The records indicate that Mrs Richards had hearing difficulties and had been awaiting new hearing aids. Records confirm that by the time of her admission to Haslar Hospital, Mrs Richards had a six-month history of falls, the last fall resulting in her fractured neck of femur on 29 July.
On 29 July, Mrs Richards was admitted to Haslar Hospital where she underwent a right cemented hemiarthroplasty (partial hip replacement).
On 5 August, Dr Richard Ian Reid assessed Mrs Richards at Haslar Hospital. He noted:
“[Mrs Richards] has been confused for some years but was mobile in her nursing home until around Christmas 1997 when she sustained a fall. She started to become increasingly noisy. She was seen by Dr V Banks who presumably felt that she was depressed as well as suffering from a dementing illness. She has been on treatment with haloperidol and trazodone. According to her daughters she has been ‘knocked-off’ by this medication … and has not spoken to them for six to seven months. Her mobility has also deteriorated during that time and when unsupervised she has a tendency to get up and fall … I believe that she is usually continent of urine but has occasional episodes of faecel incontinence. Since her operation she has been catheterized … [she] has been noisy at times … she has been continued on Haloperidol, her Trazodone has been omitted. According to her daughters … she has been much brighter mentally and has been speaking to them at times.”
Dr Reid also noted:
“Mrs Richards was confused and unable to give any coherent history … She was pleasantly cooperative [and] was able to move her left leg quite freely and although not able to actively lift her extended right leg from the bed she appeared have a little discomfort on passive movement of the right hip … [and] has been sitting out in a chair … despite her dementia she should be given the opportunity to try to re-mobilise.”
Dr Reid confirmed that he would arrange Mrs Richards’ transfer to Gosport War Memorial Hospital and noted that her daughters were unhappy with the care she had received at the nursing home.
On 11 August, Mrs Richards was discharged from Haslar Hospital and her recommended drug treatment was “Haloperidol Suspension, Lactulose and Co-codamol”, all of which were to be taken orally. The discharge letter from Haslar Hospital to Gosport War Memorial Hospital stated: “[Mrs Richards] had a right cemented semi-arthroplasty and she is not fully weight bearing. Walking with the aid of two nurses and a Zimmer.” The letter advised that Mrs Richards:
“… needed total care with washing and dressing, eating and drinking … daughters are extremely devoted and like to come in and come in and feed her at meal times … Mrs Richards has a soft diet and enjoys a cup of tea … [is] continent [and] when she becomes fidgety and agitated it means she wants the toilet, occasionally continent at night but usually wakes … Occasionally says recognizable words but not very often.”
On admission to Gosport War Memorial Hospital on 11 August, Mrs Richards was assessed by Dr Barton who recorded in the clinical notes: “transfer to Daedalus Ward for continuing care … impression frail demented lady not obviously in pain please make comfortable. Transfers with hoist, usually continent, needs help with ADL, Bartel 2. I am happy for nursing staff to confirm death.” Dr Barton wrote a prescription for morphine oral solution 2.5–5 ml (5–10 mg morphine) four hourly as required, and diamorphine 20–200 mg, hyoscine 200–800 micrograms and midazolam 20–80 mg to be administered by subcutaneous infusion over 24 hours.
The records confirm that morphine oral solution 10 mg was administered to Mrs Richards on 11 August at 14:15 and 23:45. The drug charts also confirm that haloperidol was administered to Mrs Richards on 11 August at 18:00.