Appendix 2: Detailed patient case studies

• Overall the Panel found a lack of detail in Miss Thurston’s clinical records. The clinical notes, nursing notes and nursing care plans were generally scanty.
  
• It is clear from the clinical records that, on 29 June 1999, at the time of her transfer to Gosport War Memorial Hospital, Miss Thurston was not in pain or receiving any analgesia.
  
• The Panel has not found any entries in the clinical notes for 1 and 7 July. The care plan entries for this period are scanty.
  
• The Panel has not found any document in the clinical records to show that fentanyl was clinically indicated between 1 and 25 July.
  
• At the time of Miss Thurston’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. Nurses were required to promote and protect the interests of patients.
  
• The Panel has not seen any document to confirm that nurses consulted the British National Formulary (BNF) guidance or the Wessex guidelines to scrutinise the fentanyl prescription, or that they refused to administer the fentanyl patch at any time.
  
• The relevant nursing codes of conduct and standards required nurses to be able to justify any actions taken and to be accountable for the actions taken when administering or overseeing the administration of drugs. The Panel has not seen any document in the clinical records to show the reason or rationale for the decision to commence and continue the use of fentanyl.
  

On 7 July, a five-day course of oral antibiotics was prescribed and administered.

On 8 July, Miss Thurston was assessed by Dr Victoria Banks, a psychiatrist specialising in old age. She observed that Miss Thurston seemed to have dementia; however, she was less certain about whether Miss Thurston had depression and about any contribution that this was making to her current state. Dr Banks prescribed fluoxetine regularly and haloperidol as required. She also recommended that Miss Thurston’s urinary catheter be removed and that she be treated with subcutaneous fluids and intravenous antibiotics. The nursing notes record that Dr Barton decided against intravenous antibiotics at that time.

• It is not clear from the records why antibiotics were prescribed or why Dr Banks thought they should be administered intravenously. The records suggest that the indication was related to the catheter and/or the urinary tract.
  
• The records indicate that Miss Thurston’s catheter was not removed until 11 July, when it became blocked.
  
• The Panel has not found any record to confirm that Miss Thurston was treated with subcutaneous fluids.
  
• The Panel notes that there was no facility at Gosport War Memorial Hospital for administering drugs and fluids intravenously.
  

On 13 July, Miss Thurston was re-catheterised.

On 16 July, Miss Thurston was noted to be “much more settled” with no change to her medication. The plan at that stage was to transfer her back to the nursing home. 

On 19 July, Miss Thurston was seen by Dr Reid, who agreed with the plan for placement back in the nursing home. He noted that she had pain in her knees, was refusing oral analgesia and was “better on fentanyl”. He also noted that she was more settled and more cooperative at times.

• The Panel has not seen any document in the clinical records to confirm the cause or degree of pain in Miss Thurston’s knees on 19 July.
  
• There are no entries in the clinical notes from 19 July until 25 July. The care plan entries for this period are scanty. The nature of Miss Thurston’s condition during this period is not clear.
  

On 25 July, the care plan entries record that Miss Thurston had vomited the previous evening; however, she was a “little brighter” that morning. The clinical notes confirm that Dr Beasley saw Miss Thurston later that day and noted: “Refusing all fluids and food … turned face to the wall … problems with constipation, refuses painkiller-fentanyl patches only can be used.” The nursing notes record that “Miss Thurston’s Bowels had not been opened for 10 days and that subcutaneous fluids were commenced that morning … general condition seems to be deteriorating”.

On 26 July, Dr Barton saw Miss Thurston. She made a brief note in the clinical records – “further deterioration overall … please keep comfortable. I am happy for nursing staff to confirm death” – and prescribed diamorphine 20–200 mg and midazolam 20–200 mg to be administered by 24-hour subcutaneous infusion as required. The following record was made in the nursing notes: “Syringe driver started diamorphine 90mg. Midazolam 20mg.” The drug chart records that these doses were administered at 11:15. At 19:00, a nurse confirmed Miss Thurston’s death.

Miss Thurston’s death certificate recorded the cause of death as bronchopneumonia and senile dementia.