Appendix 2: Detailed patient case studies
Case Study – Ethel Thurston
Panel comments – 4
- The Panel has not seen any document in the clinical records to confirm the nature and extent of Miss Thurston’s deterioration on 26 July.
- It was usual in the health service to use “TLC” or “make comfortable” as euphemisms for patients who were to be treated palliatively. It is not clear from the medical records why, on 26 July, Dr Barton requested nursing staff to keep Miss Thurston comfortable and why Dr Barton noted that she was “happy for nursing staff to confirm death” when Dr Reid had decided that Miss Thurston “had the physical potential to remobilise”. In addition, on 16 and 19 July, the plan was that she should return to a nursing home.
- At the time of Miss Thurston’s 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 Miss Thurston’s family or carers.
- The Panel notes the prescribing of diamorphine and midazolam in high and very wide dose ranges on 26 July.
- The Panel has not found any document in the clinical records to show that diamorphine and midazolam were clinically indicated on 26 July.
- The Panel has not found any document in the clinical records to show that the fentanyl patch was removed at any point prior to the commencement of diamorphine. The Panel notes that if the fentanyl patch had been removed when diamorphine was commenced, it would have been clinically active for several days.
- The 90 mg starting dose of diamorphine was excessive, at least three times the recommended dose equivalent when changing from a fentanyl patch to subcutaneous diamorphine.
- 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 of diamorphine and midazolam; nor did they question any of the consultants, doctors or the pharmacist at Gosport War Memorial Hospital in respect of the prescription and doses, or refuse to administer the diamorphine and midazolam.
- The Panel has not seen any document in the clinical records to show the rationale for the decision to commence the diamorphine infusion at a dose of 90 mg over 24 hours on 26 July.
- 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 diamorphine at 90 mg.
- 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 diamorphine and midazolam or the choice of starting dose.
- At the time of Miss Thurston’s 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 clinical 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 Miss Thurston’s daily nursing notes and care plans. The nursing notes and 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 ‘Urinary Incontinence Care Plan’ required daily evaluation; however, entries were made on five days only. There was nothing in the care plans that took account of Miss Thurston’s cognitive impairment, capabilities, likes, dislikes and preferences. The Panel found no pain charts or pain management plans in Miss Thurston’s medical records. It is not clear to the Panel how Miss Thurston’s pain and the effectiveness of any analgesia were adequately monitored.
- The Panel has not seen any nutrition or fluid charts among Miss Thurston’s clinical records. Fluid and nutritional intake is an important part of the clinical picture. Fentanyl, diamorphine and midazolam could impair Miss Thurston’s ability to eat and drink.
- In addition to its intended effects, morphine might also have a number of side effects on a patient, including discomfort, agitation and respiratory depression. The Panel has not seen any document in the clinical records to show that the nurses treating Miss Thurston understood or took into account these possible side effects of morphine when noting Miss Thurston’s condition. 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.
- The Panel has not found any document in the medical records to show any evidence of bronchopneumonia.
- The Panel has not found any document in the medical records to show that any discussion took place with Miss Thurston’s family or carers about her treatment.
- Miss Thurston died approximately eight hours after the first, large and only dose of diamorphine.