Appendix 2: Detailed patient case studies

• The Panel notes the anticipatory prescribing of morphine oral solution.
  
• The Panel notes the anticipatory prescribing of diamorphine, hyoscine and midazolam in high and very wide dose ranges.
  
• The Panel has not found any document in the clinical records to show that morphine oral solution, diamorphine, midazolam and hyoscine were clinically indicated on 11 August.
  
• The Panel has not found any document in the clinical records to confirm Dr Barton’s rationale for prescribing morphine oral solution, diamorphine, midazolam and hyoscine on 11 August.
  
• It is not clear from the clinical records why, having noted Mrs Richards as “not obviously in pain”, Dr Barton prescribed morphine oral solution and diamorphine.
  
• It was usual in the health service to use “TLC” (tender loving care) or “make comfortable” as euphemisms for patients who were to be treated palliatively.
  
• It is not clear from the medical records why Dr Barton requested that Mrs Richards be “made comfortable” and why Dr Barton noted that she was “happy for nursing staff to confirm death” in circumstances where Dr Reid had decided Mrs Richards should be given the “opportunity to ... re-mobilise”.
  

In relation to her note “happy for nursing staff to confirm death”, Dr Barton stated during an interview with Hampshire Constabulary in July 2000:

During the GMC Fitness to Practise (FtP) hearing in 2009, Dr Barton stated:

In her police interview, in relation to the prescription of morphine oral solution and diamorphine on 11 August, Dr Barton stated:

During the FtP hearing, Dr Barton stated:

In relation to the prescription of diamorphine, Dr Barton said:

Dr Barton went on to state that post-operative analgesia was often inadequate and she would have expected Mrs Richards to still be in pain when she was transferred to Gosport War Memorial Hospital.

• The Panel has found no documents in the clinical records to confirm that Mrs Richards was screaming as if in pain on 11 or 12 August.
  
• Dr Barton did not record any of the above views in Mrs Richards’ clinical notes at the time of her admission and, given Dr Reid’s view that Mrs Richards should be given the opportunity to remobilise, and Haslar Hospital had prescribed co-codamol only, it is not clear to the Panel why Dr Barton did not discuss her views and prognosis with Mrs Richards’ consultant or any members of her family.
  
• At the time of Mrs Richards’ 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 Richards’ family.
  
• At the time of Mrs Richards’ 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 Richards challenged the proactive and wide dose range prescriptions of morphine oral solution, 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 relevant nursing codes of conduct and standards required nurses to be able to justify and be accountable for any actions taken when administering or overseeing the administration of drugs. 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 document in the clinical records to show the reason or rationale for the decision to commence morphine oral solution on 11 and 12 August, or for the choice of a 10 mg starting dose.
  
• The Panel has not seen any 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 morphine oral solution to Mrs Richards or when choosing a 10 mg starting dose, which was the higher dose on the range prescribed by Dr Barton.
  
• 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 morphine oral solution or the choice of starting dose.
  
• At the time of Mrs Richards’ 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 information in Mrs Richards’ 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, the ‘Personal Hygiene’ care plan appeared to be a typed proforma and stated: “patient is unable to maintain own personal hygiene … ensure patient is clean or comfortable at a level acceptable to him or her”. There was nothing that took account of Mrs Richards’ cognitive impairment, capabilities, likes, dislikes and preferences. The Panel found no pain charts or pain management plans in Mrs Richards’ medical records. It is not clear to the Panel how Mrs Richards’ pain and the effectiveness of analgesia were adequately monitored. The Panel has found no document to confirm that any assessment of Mrs Richards’ cognitive impairment was carried out or was the subject of a care plan.
  
• The Panel has not seen any fluid charts among Mrs Richards’ medical records and the nutrition plan was a proforma which contained entries for 13, 14 and 21 August only. Fluid and nutritional intake was an important part of the clinical picture. Morphine oral solution, diamorphine and midazolam could impair the ability to eat and drink.
  

On 12 August 1998, Dr Barton wrote further prescriptions for morphine oral solution 2.5–5 ml (5–10 mg morphine) four hourly, and 5 ml (10 mg morphine) in the evening as required. The records confirm that morphine oral solution 10 mg was administered to Mrs Richards at 06:15. Nursing notes for the evening of 12 August recorded, at 18:00, “patient drowsy” and, at 23:00, that Mrs Richards was having difficulty settling at night and was agitated, shouting and crying but that “she did not seem to be in pain”. There are no clinical notes on 12 August.