Appendix 2: Detailed patient case studies
Case Study – Gladys Richards
Panel comments – 3
- The Panel has not found any document in the medical records to show that morphine oral solution was clinically indicated on 12 August.
- The Panel notes that following the administration of three doses of morphine oral solution 10 mg on 11 and 12 August, Mrs Richards was noted to be “drowsy”.
On 13 August, the nursing notes record:
“… found on the floor at 13.30 hours checked for injury none apparent at time hoisted into safer chair. At 19.30 pain rt hip internally rotated. Dr Brigg contacted advised Xray AM and analgesia during the night. Inappropriate to transfer for Xray this PM. Daughter informed.”
The drug chart and nursing notes confirm that Mrs Richards was given morphine oral solution at 20:50 and that she “slept well”. There are no clinical notes on 13 August.
On 14 August, the nursing notes record “some pain in rt leg?/hip this am” and that Mrs Richards ate porridge. Dr Barton noted in the clinical records:
“… sedation/pain relief has been a problem screaming not controlled by Haloperidol … very sensitive to [morphine oral solution]. Fell out of chair last night Right hip shortened and internally rotated daughter aware and not happy please X-ray. Is this lady well enough for another surgical procedure?”
The drug chart confirms that morphine oral solution 5 ml (10 mg) was administered to Mrs Richards at 11:50.
Dr Barton saw Mrs Richards again later that day after the X-ray and contacted Surgeon Commander Spalding at Haslar Hospital. The note records that she relayed Mrs Richards’ history of a dislocated hip, sent him Mrs Richards’ X-rays and informed him that Mrs Richards had been given morphine oral solution at midday. Later that day, the nursing notes record that Mrs Richards’ hip was dislocated and she was to be transferred to Haslar Hospital “for reduction under sedation”.
In the police interview in July 2000, Dr Barton stated: “Although I was concerned, given Mrs Richards’ overall condition and her frailty that she might not be well enough for another surgical procedure, I felt that this clearly would be a matter for assessment by the clinicians at Haslar.”
On the same day, Nurse Philip Beed wrote to Haslar Hospital. He confirmed Mrs Richards’ transfer to the accident and emergency department for a reduction of her dislocated hip and that there had been no change in her treatment since her admission to Gosport War Memorial Hospital on 11 August, “except addition of [morphine oral solution]”. He confirmed that 10 mg of morphine oral solution had been given to Mrs Richards at 11:50 and that Gosport War Memorial Hospital would be happy to take Mrs Richards back after the reduction.
On 17 August, Mrs Richards was discharged from Haslar Hospital and transferred back to Gosport War Memorial Hospital. The discharge letter confirmed that Mrs Richards "underwent a closed reduction under IV sedation. The reduction was uneventful. However she was rather unresponsive following the sedation then gradually become more responsive but was unable to pass urine.” Mrs Richards was given 2 mg of midazolam as sedation for the reduction procedure. The letter confirms that Mrs Richards had been catheterised and had been given a canvas knee-immobilising splint “to discourage any further dislocation”. The splint was required to stay in place for four weeks. The letter made it clear that Mrs Richards could “mobilise fully weight bearing” and that when she was in bed it was advisable to encourage abduction by use of pillows or an abduction wedge.
The nursing notes record that, at 11:48, Mrs Richards had returned to Gosport War Memorial Hospital and was very distressed and appeared to be in pain. The notes record that Mrs Richards had been transferred by the ambulance crew on a sheet and not canvas. The nursing notes record the advice from Haslar Hospital that abduction in bed should be encouraged and specifically the advice from Haslar Hospital that there would be “no follow up unless complication”. At 13:05 the Gosport War Memorial Hospital records further note that Mrs Richards was in pain and distress and that “2.5 mg in 5 ml” of morphine oral solution was given to her, although the drug charts record the dose given as 2.5 ml (5 mg morphine). The notes record that Mrs Richards’ daughter had informed staff that the surgeon had said “must not be left in pain if dislocation occurs again”. The note records that Dr Barton was contacted and she ordered that an X-ray be carried out. The nursing record ends: “PM Hip Xrayed … no dislocation seen … for pain control overnight and review by Dr Barton.”
Mrs Richards was given three 2.5 ml doses of morphine oral solution (5 mg morphine) and one 5 ml dose of morphine oral solution (10 mg morphine) between 13:00 and 20:30 on 17 August.
Dr Barton’s untimed clinical note records: “readmission … from RHH. Closed reduction under IV sedation. Remained unresponsive for some hours. Now appears peaceful. Please continue Haloperidol. Only give [morphine oral solution] if in severe pain.”
In her police interview in July 2000, Dr Barton stated:
“At the time of her arrival back on the ward Mrs Richards appeared peaceful and not in severe pain. This was however an initial judgement made on an assessment shortly after her arrival on the ward. I was concerned that she should have opiates only if her pain became a problem, and I altered her drug chart accordingly. I was not aware at that time that she had been having intravenous morphine at [Haslar Hospital] until shortly before her transfer. This would have explained why at this time she appeared to be peaceful and not in pain.”
Panel comments – 4
- It is not clear to the Panel at what time Dr Barton first saw Mrs Richards on 17 August. However, it is clear from the nursing notes that Mrs Richards arrived on the ward around 11:50 and was in distress and pain and therefore was not peaceful on her arrival at Gosport War Memorial Hospital. It is also clear that Mrs Richards was noted to be in pain and distress again at 13:05 when a dose of morphine oral solution was administered to her. During the FtP hearing Dr Barton confirmed that she must have seen Mrs Richards after she had received this dose of morphine oral solution, that Mrs Richards had not received intravenous morphine at Haslar Hospital, and that this was an error in her police statement.
On 18 August, Mrs Richards was given two 5 ml doses of morphine oral solution (10 mg morphine) between 02:30 and 04:30. Dr Barton later noted, “still in great pain, nursing a problem I suggest s.c. [subcutaneous] diamorphine / haloperidol / midazolam … please make comfortable”. The drug charts confirm that Dr Barton wrote another prescription for diamorphine 40–200 mg subcutaneously over 24 hours. In the later police interview, Dr Barton stated that when she examined Mrs Richards there was a lot of swelling and tenderness around the area of the prosthesis. It was her assessment that Mrs Richards had “developed a haematoma or a large collection of bruising around the area where the dislocated prosthesis had been lying whilst dislocated” and that this was in all probability the cause of the pain. Dr Barton confirmed her view that “this complication would not have been amenable to any surgical intervention” and that transfer to Haslar Hospital was not in Mrs Richards’ best interests.
During the FtP hearing, Dr Barton stated:
“[Mrs Richards] was not well enough to return to the acute orthopaedic ward. We knew she had a large haematoma, or bruise, around where the dislocation had been put back. I knew that nothing surgically could have been done for this condition and that it would just have to be allowed to heal in its own time, if her condition permitted and she remained well enough … I did not feel that a transfer back to an acute unit at that point was in [Mrs Richards’] interests. She probably would not have even survived the journey back, so we had to continue on our route of palliative care, becoming terminal care.”