Appendix 2: Detailed patient case studies
Case Study – Elsie Devine
Summary of hospital admission
- In 1999, Elsie Devine was aged 88 and lived with her daughter and her family.
- On 9 October, she was admitted to Queen Alexandra Hospital. In the days before admission she had become confused and aggressive and had been found wandering.
- On 20 October, she was deemed to be “suitable for a rehabilitation programme” and fit for discharge.
- On 21 October, she was admitted to Gosport War Memorial Hospital for rehabilitation.
- On 15 November, she became restless and aggressive and on 18 November a locum staff psychiatrist from the Department of Elderly Mental Health assessed her and noted: “This lady has deteriorated and has become much more restless and aggressive again. She’s refusing medication and not eating well.”
- On 21 November 1999, Mrs Devine died on Dryad Ward at Gosport War Memorial Hospital at 20:30.
Background, care and treatment
In 1999, Mrs Devine was aged 88. She had one daughter and one son and lived with her daughter and her family. Mrs Devine had lost her husband 21 years earlier but had remained independent and self-caring, able to do her own cooking and cleaning. In January 1999, she started to experience some decline in her memory. Mrs Devine had a history of moderate chronic renal failure and in April the possibility of her having myeloma was considered.
Records confirm that Mrs Devine had an IgA lambda paraprotein, but no Bence-Jones proteins, and nephrotic syndrome. (Paraproteins and Bence-Jones proteins are found in multiple myeloma.) On 15 April, Dr Bob Logan, a consultant geriatrician, referred her to a haematologist to investigate whether she had myeloma. The referral letter stated: “I would be very grateful for your help in managing this charming 87-year-old lady who is moderately frail, but is very bright mentally.”
A skeletal survey was carried out. Myeloma was not diagnosed but an IgA paraprotein was present.
On 20 July 1999, Mrs Devine was seen by Dr Lennon in Dr Stevens’ outpatient clinic. Dr Stevens was a consultant renal physician. Dr Lennon recorded:
“She remains well on her current treatment with no new problems … her blood test show that her creatinine is slowly worsening and was 192 on the test sample taken. Her albumin is also low at 22. On examination she had oedema to above the knee plus a small sacral pad which may have been from waiting in the waiting room. JVP not raised, heart sounds normal, chest was clear. My impression is that she is stable and weight loss is probably secondary to increased fluid loss with her Frumil … there is no therapeutic intervention which we may undertake at this point.”
On 7 September, Dr Stevens saw Mrs Devine in outpatients. She recorded:
“Problems: Chronic renal failure with small kidneys; nephrotic (syndrome); IgA lambda paraprotein. Mrs Devine’s oedema is marked up to her knees. Unfortunately, she has no record of her drugs with her so I was unable to change the dose of diuretics. I think her oedema would benefit from an increase. Blood pressure today was well controlled at 130/70 … Her creatinine is showing gradual rise and in July it was up to 192.”
Mrs Devine’s creatinine value was 203.
On 9 October, Mrs Devine was admitted to Queen Alexandra Hospital. In the days before admission she had become confused and aggressive and had been found wandering. The referral letter states: “Confused for 2 days, aggressive and wandering. No history of SDAT [senile dementia of Alzheimer type].” Mrs Devine was treated with antibiotics for a urinary tract infection (UTI) and was referred to the Mental Health Team.
On 15 October, Dr Taylor, a clinical assistant in old age psychiatry, saw Mrs Devine on the ward at Queen Alexandra Hospital and recorded:
“I understand that she was admitted on 9.10.99 with an episode of acute confusion. Her daughter says that she did not know who she was, did not know where she was, wandering and aggressive. On the ward apparently she remained acutely confused, trying to get out of windows and possibly hallucinating, although I understand that her behaviour has settled. She remains confused and disorientated but is no longer aggressive or difficult in her behaviour, and is now sleeping better … Up until January of this year [Mrs Devine] was able to look after herself, doing all her cooking and cleaning, but since January the family have noticed a decline in her memory. She has stopped being able to cook and has required somebody to look after her. This seems to have come on since her diagnosis with multiple myeloma back in January.”
The letter noted that Mrs Devine’s daughter was unable to continue to care for her mother at this time and continued:
“Past medical history:… Multiple myeloma and hyperthyroidism … There is no known psychiatric history. Current medication: Thyroxine 100mcg daily, Frusemide 80mgs daily, Amiloride 5mgs daily and Cefaclor 37.5mgs bd for presumed UTI, which was thought to be the reason for her coming in to hospital. The staff tell me that she is mobile, she is able to wash with prompting, she takes herself to the toilet and is independent in her self-care, but does tend to get lost around the ward and needs prompting. She is now sleeping well and settled during the day, but apparently is quite aggressive towards her daughter, and feels that her daughter has put her away. On examination of her mental state: She was in her nightie. She was very calm and co-operative and quite friendly. Her speech was normal in rate and form and [Mrs Devine] denied feeling unhappy. At the time of seeing her there was no evidence of delusions or hallucinations, but she did think her daughter was on holiday, and she had no idea where she was. She herself feels that she has no problems with her memory, but unfortunately she only scored 9/30 on an MMSE [mini mental state examination]. She is very deaf and may not have heard or understood a lot of what I was saying because of this. I am sure this lady has a diagnosis of dementia, how much this is related to her underlying myeloma I do not know, but the situation seems to be that she cannot return home, and would therefore recommend referring her to Social Services for Residential Care, and recommend that she needs 24-hour care with a Home that has experience in dealing with memory problems, but currently she does not need an EMI [elderly mentally infirm] Home, as her behaviour is settled. However, if her behaviour deteriorates whilst in hospital, let us know and we will consider transferring her to Mulberry for further assessment.”
On the same day, Dr Taylor wrote to social services and expressed the view that Mrs Devine was “suitable for experienced residential care”.
On 18 October, a CT scan of Mrs Devine's brain was carried out. The scan report noted: “Involutional and Ischaemic changes present.”
On 20 October, Mrs Devine was assessed by Dr Jayawardena, a consultant geriatrician on the ward at Queen Alexandra Hospital. He reported:
“I visited Mrs Devine, an 88 year old Lady, who suffers from moderate chronic renal failure and was admitted with a history of a urinary tract infection. She has recovered from the above problems. She is quite alert, can stand and rather unsteady on walking. I found her chest clear, no evidence of cardiac failure and I find her suitable for a rehabilitation programme. The patient requests to be transferred to Gosport War Memorial Hospital and I will make arrangements for this.”
The transfer letter stated:
“… [patient] admitted with [inconclusive] confusion ?UTI. Originally was at times aggressive but this has resolved now she knows us better. Due to her CRF [chronic renal failure] we treated her for a UTI and apart from needing guidance and reassurance is self-caring. Her social circumstances have changed drastically and she needs temporary placement with you until a permanent place is [found].”
By this time, Mrs Devine had been diagnosed with dementia. However, her condition had improved, her behaviour was settled and she was ready for discharge from Queen Alexandra Hospital. At this stage she was described as alert and able to stand, although she was unsteady on her feet. Her chest was clear, there was no evidence of cardiac failure and she was deemed suitable for a rehabilitation programme. Although she was fit for discharge, Mrs Devine could not return home at this time because of an illness in the family. The hospital had arranged for her to be transferred to a care home but her daughter was very concerned about this placement and insisted that she be transferred to Gosport War Memorial Hospital.
On 21 October, Mrs Devine was transferred to Dryad Ward at Gosport War Memorial Hospital under the care of Dr Richard Ian Reid, pending her return home or discharge to an appropriate residential home. The admission record confirms her diagnosis to be chronic renal failure.
On admission, Mrs Devine was assessed by Dr Jane Barton, who noted:
“… transfer to Dryad Ward continuing care HPC [history of present condition] acute confusion admitted to Mulberry-QA-Dryad (Mulberry details not reviewed). PMH [past medical history] Dementia, Myeloma, Hypothyroidism. Bartel,- transfers with one, so far continent, needs some help with ADL. MMSE 9/30. Bartel - (8/30) Plan: - get to know, assess rehab. potential, probably for rest home in due course.”