Appendix 2: Detailed patient case studies

• Dr Barton did not record the explanations for the increase in the prescribed doses she provided to the police in Mr Cunningham’s clinical notes at the time of her assessment.
  
• The Panel has not seen any document in the clinical records to confirm the rationale for the increased dose of diamorphine and hyoscine.
  

On 26 September, the drug charts confirm that at 11:50 diamorphine 80 mg, midazolam 100 mg and hyoscine 1,200 micrograms were given by syringe driver over 24 hours.

• The Panel has not seen any document in the clinical records to confirm the rationale for the increase in diamorphine and midazolam.
  
• In her police interview, Dr Barton stated: “I anticipate that Mr CUNNINGHAM was experiencing further pain and distress, necessitating the increase, and that Dr BROOK would have agreed with it, though it is also possible that I might have been contacted prior to the increase by the nursing staff instead. In view of Mr CUNNINGHAM’S condition, with the significant pain from the large sacral sore, and the fact that he would have been becoming inured to the medication, that increase would have been necessary.”
  
• During the FtP hearing, Dr Barton confirmed that 26 September was a Saturday, that she did not see Mr Cunningham on this day and that she assumed he would have been seen by the duty doctor.
  
• Dr Barton did not record the explanations for the increase in the prescribed doses she provided to the police in Mr Cunningham’s clinical notes at the time of her assessment.
  

The clinical records note that, on 26 September: “[Mr Cunningham’s] condition continued to deteriorate [and he] died 23:15.”

Nursing care plans were created for ‘assistance to sleep’, ‘large sacral sore’, ‘blister on heel’, ‘assistance with personal hygiene’ and ‘catheterised’.

• At the time of Mr Cunningham’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 Mr Cunningham’s family.
  
• At the time of Mr Cunningham’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. The Panel has not seen any document to confirm that nurses treating Mr Cunningham challenged the proactive and repeated high and wide dose range prescription of diamorphine, midazolam and hyoscine. 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; nor did they question any of the consultants, doctors or the pharmacist at Gosport War Memorial Hospital in respect of the prescription and doses.
  
• The Panel notes that the relevant nursing codes of conduct and standards provided that, when administering or overseeing the administration of drugs, nurses should be able to justify and be accountable for any actions taken.
  
• The Panel has not seen any nursing document in the clinical records to show the reason or rationale for the decision to commence and continue the use of diamorphine and midazolam.
  
• The Panel has not seen any nursing 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 and midazolam.
  
• 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.
  
• At the time of Mr Cunningham’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 medical 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 care plans seen by the Panel were limited in detail, were not personalised to the patient’s needs and did not take account of Mr Cunningham’s capabilities, likes, dislikes and preferences. The Panel found no pain charts or pain management plans in Mr Cunningham’s clinical records. It is not clear to the Panel how Mr Cunningham’s pain and the effectiveness of any analgesia were to be adequately monitored.
  
• The Panel has not seen any fluid charts or nutrition plan among Mr Cunningham’s clinical records. Fluid and nutritional intake was an important part of the clinical picture. Diamorphine and midazolam could impair the ability to eat and drink.
  
• 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 Mr Cunningham understood or took into account these possible side effects of morphine when noting Mr Cunningham’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.