Appendix 2: Detailed patient case studies
Case Study – Gladys Richards
Panel comments – 5
- The Panel notes that Dr Barton did not consult the clinicians at Haslar Hospital about Mrs Richards’ haematoma, treatment and transfer, having previously decided that consultation was necessary.
- The Haslar Hospital transfer letter stated “no follow up unless complication”. It is not clear to the Panel why Dr Barton did not consult the clinicians at Haslar Hospital in light of the apparent complication.
- It is not clear to the Panel why Dr Barton did not investigate the presence and the nature of any haematoma.
- It is not clear to the Panel on what basis Dr Barton determined that any haematoma was not amenable to surgical intervention or any other form of treatment.
- It is not clear to the Panel why Dr Barton did not record this diagnosis and view in her clinical notes at the time she assessed Mrs Richards. There are also no nursing notes to reflect this diagnosis.
On 18 August, the nursing notes state: “reviewed by Dr Barton, for pain control via syringe driver”. The records confirm that at 11:45 the administration of diamorphine 40 mg, haloperidol 5 mg and midazolam 20 mg was commenced by syringe driver.
In the later police interview, Dr Barton confirmed her rationale for prescribing the subcutaneous administration of diamorphine as follows:
“I explained that it was the most appropriate drug as their mother was not eating or drinking or able to swallow, subcutaneous infusion … was the best way to control her pain … this drug, the dose used and this mode of administration are standard procedures for patients who are in great pain but who cannot take medicines by mouth.”
Dr Barton went on to explain that Mrs Richards had not responded to 45 mg of morphine oral solution over the previous 24 hours, so it was necessary to introduce the use of diamorphine.
During the FtP hearing, Dr Barton stated:
“I calculated the number of doses of [morphine oral solution] she had had in the preceding 24 hours and the conversion for that should have been approximately 20mg, but her pain was not controlled so I was minded to increase it, hence 40mg and agreed that in effect, if the figure with regard to the [morphine oral solution] was a total of 45 in the previous 24 hours.”
Dr Barton stated that this was an “appropriate starting dose for [Mrs Richards’] symptoms”.
Panel comments – 6
- The Panel has found no document in the medical records to confirm Dr Barton’s rationale for increasing the dose range of diamorphine to 40–200 mg.
- The Panel notes that the administration of diamorphine 40 mg over 24 hours by syringe driver in a patient who had received 45 mg of morphine oral solution in the previous 24 hours constitutes more than a doubling of the effective dose of morphine. The Panel can find no justification in the clinical records for this increase in dosage.
- As noted above, the Panel has not found any pain management records for Mrs Richards; accordingly, it is not clear on what basis Mrs Richards’ response to analgesia was being assessed and determined.
- The Panel has not found any document in the clinical records to show that on 18 August the nurses scrutinised or questioned Dr Barton’s prescription of diamorphine and midazolam or refused to administer these drugs.
- It is also not clear from the records on what basis Dr Barton had concluded that Mrs Richards was not eating, drinking or able to swallow. The Panel has not found any fluid charts in the clinical records.
At 20:00, the nursing notes record that Mrs Richards remained peaceful and sleeping but “reacted to pain when being moved”. This was noted to be pain in both legs.
Panel comments – 7
- 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 Richards understood or took into account these possible side effects of morphine when noting Mrs Richards’ reaction to being moved. 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.
On 19 August, the nursing notes record that Mrs Richards’ grandson wished to speak with Dr Barton or Nurse Beed later that day, and that Mrs Richards’ daughter was “not happy with various aspects of care. Complaint to be handled officially by S Hutchings Nursing Co-ordinator.” The drug chart confirms that diamorphine 40 mg, midazolam 20 mg, haloperidol 5 mg and hyoscine 400 micrograms were administered by syringe driver at 11:20. There are no clinical notes on 19 August.
On 20 August, there are no clinical notes or nursing notes. The drug charts confirm that diamorphine, midazolam, hyoscine and haloperidol continued to be given to Mrs Richards until 21 August.
On 21 August, at 11:55, Dr Barton noted “much more peaceful, needs Hyoscine for rattily chest" . At 21:20, Staff Nurse Sylvia Giffin recorded Mrs Richards’ death.