Appendix 2: Detailed patient case studies
Case Study – Elsie Devine
Panel comments – 1
- The Panel has not seen any document to confirm that Mrs Devine went to Mulberry Ward before being transferred to Dryad Ward.
The nursing notes record:
“… admitted this PM from F3 QAH. Was admitted due to increasing confusion and aggression. The aggression has now resolved. Still seems confused at times. Has [chronic renal failure] needs minimal assistance with ADLs. A very pleasant lady. Her appetite on the whole is not good and can be a little unsteady on her feet.”
Dr Barton then prescribed morphine oral solution 2.5–5 ml (5–10 mg morphine) four hourly.
Panel comments – 2
- There are no medical records to confirm on what basis Dr Barton prescribed morphine oral solution.
- The Panel has not seen any record to confirm that this drug was clinically indicated at any time.
In relation to the morphine oral solution prescription, Dr Barton stated in a police interview in April 2006: “I was concerned that a low dose of pain relieving medication should be available for [Mrs Devine] in case she experienced distress and discomfort and a Doctor was not available to write up a prescription for her.”
During the 2009 GMC Fitness to Practise (FtP) hearing, Dr Barton stated:
“At some time in the future, during her admission I imagine that she might suffer from pain from her chronic renal problem or pain and distress at the end stages of her dementia, and I wanted to have it there on the drug chart should we need it in the future. I was not anticipating using the drug at that time … We did use it in the confusion that we saw in end-stage dementia, because it was very difficult to find something to make somebody comfortable at that end of their life, even in terminal dementia … Confusion, mental distress, agitation, fear: all a spectrum of emotions with or without an element of psychological pain behind them, very difficult to distinguish, very difficult to treat, very difficult to look after. Sometimes these people deserved a small dose of opiate.”
Panel comments – 3
- The Panel notes that Dr Barton did not record her rationale in the clinical notes at the time this decision was made.
- The Panel notes that Dr Barton did not prescribe simple analgesia.
- Dr Barton did not record the explanation for prescribing morphine oral solution she provided to the police in Mrs Devine’s clinical notes at the time of her assessment.
- The Panel has not seen any record of administration of morphine oral solution.
On 25 October 1999, Dr Reid assessed Mrs Devine and noted that she was “Mobile unaided, washes with supervision, dresses self, continent, mildly confused”.
On 1 November, Dr Reid assessed Mrs Devine again and noted that she was “physically independent but needs supervision with washing and dressing, help with bathing. Continent. Quite confused and disorientated e.g. undressing during the day is unlikely to get much social support at home.” Dr Reid prescribed amiloride.
On 10 November, Mrs Devine was noted to be confused and wandering. The following day Dr Barton prescribed temazepam, trimethroprim and thioridazine.
In relation to the thioridazine, during the 2009 FtP hearing Dr Barton stated:
“… because we thought clinically she had a urinary tract infection at that time. Thioridazine is a major tranquiliser. The wandering around the ward became quite difficult to manage on an open geriatric ward quite invasive for the other patients and difficult for the staff and that was an attempt to keep her behaviour more in keeping with the rest of the ward. Not a chemical cosh in any way, but just to make her a bit less restless and agitated.”
By 11 November, the plan was to arrange for Mrs Devine to visit her home twice weekly to see her family and to assess if she would function better in her own home.
By 15 November, when Dr Reid assessed her, Mrs Devine had become restless and aggressive. Dr Reid noted:
“… very aggressive at times, has needed thioridazine. On treatment for UTI; MSU sent, blood and protein in urine. Examined by Dr Reid: Pulse 100, regular. Temperature 36.4, JVP not raised, hepato-jugular reflex +ve. Heart sounds- nil added. Oedema +++ to thighs. Chest clear. Bowels regular- PR empty 13.11.99. but good bowel action since. (MSU* -no growth). Ask Dr Lusznat to see.”
The nursing care plan records confirm that: between 21 October and 13 November Mrs Devine regularly opened her bowels; between 21 October and 20 November she slept well, except for 10 November when she wandered during the night, and 15 November when she got up to use the toilet and was “disruptive before settling” ; and between 21 October and 18 November she bathed and washed daily with assistance.