Appendix 2: Detailed patient case studies
Case Study – Elsie Devine
Panel comments – 4
- There are no bowel movement notes after 13 November.
- There are no personal hygiene notes after 18 November.
On 18 November, a locum staff psychiatrist from the Department of Elderly Mental Health assessed Mrs Devine and noted:
“This lady has deteriorated and has become much more restless and aggressive again. She’s refusing medication and not eating well. She does not seem to be depressed and her physical condition is stable. I'll arrange for her to go to Mulberry.”
Mrs Devine’s physical condition was noted to be stable and plans were made to transfer her to Mulberry Ward. Dr Barton prescribed a 25 microgram fentanyl patch every three days.
Panel comments – 5
- The Panel has not seen any record to confirm that fentanyl was clinically indicated.
In relation to the fentanyl prescription, Dr Barton stated during an interview with Hampshire Constabulary in November 2004:
“Having received the blood test results, it became apparent that transfer would not be appropriate, even if a bed did become available, and that her medical condition was deteriorating significantly, accompanied by marked restlessness and agitation. After discussion amongst the team who were concerned about her obvious discomfort, and given the fact she was refusing to take medication, I decided to commence a Fentanyl 25 mcg patch on the skin. This was in an attempt to calm her, to make her more comfortable, and to enable nursing care. [Mrs Devine] was not eating or drinking well by this stage. I did not feel that a subcutaneous infusion would be helpful at that point as she was likely simply to remove it.”
During the 2009 FtP hearing, Dr Barton stated:
“She was aggressive, wandering, moving other people's clothes, refusing medication, so anything that I was going to give her to make her more comfortable and peaceful would not be an oral agent because she would refuse it or spit it out. I was looking at a parenteral preparation to ease these symptoms. In my mind at that point she was becoming end-stage dementia which are the most difficult patients to look after and make comfortable because of all those things you talked about: What is the pain? Where is the pain? superimposed on her deteriorating renal function. So she had two major comorbidities, she was becoming very unwell, and I thought that a transdermal patch at that point in time was a kinder way of controlling her symptoms. Subcutaneous infusion would have been very difficult to administer in somebody who was that restless and aggressive … I think I probably would have gone for the [morphine oral solution] and carried on with a higher dose of the thioridazine, but that was becoming impossible to give because she did not want to take the tablets.”
In relation to the presence of pain, Dr Barton stated:
“Not physical pain but not happy, not comfortable, not easy to look after. Restless, wandering, climbing into other people’s beds: not a picture of a lady who was at peace with herself, although there were no physical signs of pain.”
Panel comments – 6
- The Panel notes that Dr Barton did not record the rationale provided to the police and the FtP hearing in the clinical notes at the time this decision was made.
- The Panel has not seen any record of Mrs Devine experiencing pain.
- The Panel has not seen any fluid charts in the medical records. In the case of a patient with renal failure, fluid management is essential.
- The Panel has not seen any record to confirm that there were adequate attempts to rehydrate Mrs Devine.
- The Panel found no document in the medical records to confirm Dr Barton’s rationale for prescribing fentanyl. It is clear from later records that the fentanyl patch was administered; however, this is not recorded on the drug chart. The Panel observes that the use of fentanyl might have compounded the deterioration in Mrs Devine’s mental state.
On 19 November, Dr Barton assessed Mrs Devine and noted that there had been:
“… [a] marked deterioration overnight, confused, aggressive. Creatinine 360. Fentanyl patch commenced yesterday; today further deterioration in general condition needs subcutaneous analgesia with midazolam. Son seen and aware of condition and diagnosis. Please make comfortable; I’m happy for nursing staff to confirm death.”
Dr Barton prescribed a subcutaneous infusion of diamorphine 40–80 mg and midazolam 20–80 mg over 24 hours.
The nursing notes record:
“… marked deterioration over the last 24 hours. Extremely aggressive this am refusing all help from all staff. chlorpromazine 50mg given [intra muscularly] at 08.30. Taken two staff to special. Syringe driver commenced at 09.25 Diamorphine 40mg and Midazolam 40mg. Fentanyl Patch removed.”