Appendix 2: Detailed patient case studies
Case Study – Arthur Cunningham
Panel comments – 3
- The Panel notes that the syringe driver was renewed at 20:00 with an increased dose of midazolam.
- The Panel has not seen any document in the clinical records to confirm the rationale for the three-fold increase in the dose of midazolam commenced at 20:00 on 23 September.
- The Panel feels that in light of the reported anxiety of Mr Cunningham’s son, an appointment with a consultant should have been made.
In her police interview, Dr Barton stated:
“I anticipate that Mr CUNNINGHAM’S agitation might have been increasing, hence the increase in the level of Midazolam, and indeed in spite of that, the notes go on to record that Mr CUNNINGHAM became a little agitated at 11 p.m. with the syringe driver being boosted with effect. The nursing staff recorded that Mr CUNNINGHAM seemed to be in some discomfort when moved, and the driver was boosted prior to changing position. Again, I anticipate that I would have been contacted about the increase in the medication and agreed with it, though I have got no recollection of this.”
During the FtP hearing, Dr Barton stated:
“This would have been the picture of a man whose pain relief seemed adequate, so the diamorphine was kept at the same level but that he was becoming now terminally restless. This would have been in association with the bronchopneumonia he was now developing, hence the reason for administering the hyoscine and also increasing the midazolam. We wanted reduction of anxiety. There must be nothing worse than listening to your secretions in your throat and not being able to clear them, and also a muscle relaxant for him … [this was] adequate sedation to make him comfortable during this terminal phase of his life not excessive sedation, but adequate, so that he was not frightened and anxious as he approached death.”
Panel comments – 4
- Dr Barton did not record the explanations for the three-fold increase in midazolam she provided to the police or to the FtP hearing in Mr Cunningham’s clinical notes at the time of her assessment.
The nursing notes record: “Became a little agitated at 23:00hrs, syringe driver boosted with effect. Seems in some discomfort when moved, driver boosted prior to position change.” The notes further record that Mr Cunningham’s catheter was draining but the urine was very concentrated.
Panel comments – 5
- The Panel notes that the 23:00 boost was not recorded in the drug chart. The Panel has not seen any record to confirm the magnitude of the increase in dose.
On 24 September, the nursing notes record that Mr Cunningham was in pain when attended to, and that the diamorphine, midazolam and hyoscine had been increased at 10:55.
The drug chart confirms that at 10:55 Mr Cunningham was commenced on diamorphine 40 mg, midazolam 80 mg and hyoscine 800 micrograms by syringe driver over 24 hours.
Dr Barton assessed Mr Cunningham and recorded in the clinical notes: “Remains unwell. Son has visited again today and is aware of how unwell he is. sc analgesia is controlling pain just. I am happy for nursing staff to confirm death.”