Appendix 2: Detailed patient case studies
Case Study – Elsie Devine
Panel comments – 7
- The Panel has not seen any record to confirm that diamorphine and midazolam were clinically indicated at this time. In addition, the Panel has not seen any document in the medical records to confirm the rationale for the high starting doses.
In relation to the diamorphine and midazolam prescription, Dr Barton stated in her police interview:
“… on the morning of 19th November I found [Mrs Devine] in an extremely aggressive state, hanging onto the bars in the main corridor of the ward. She was clearly very agitated, anxious, and distressed. She would not allow anyone to approach her or administer any of her usual medication; In due course we were able to administer 50mg of Chlorpromazine intramuscularly. This took some time to be effective, but in due course we were able to get her back into her own bed. This major tranquilliser had made her quite drowsy and we made the decision to discontinue the transdermal Fentanyl which I knew would have taken about 22 hours to reach steady state drug levels, and to opt instead for subcutaneous analgesia. As [Mrs Devine] had already received opiates in the form of the Fentanyl, and had been resistant to this to a degree, I prescribed 40mgs of Diamorphine, to be administered via syringe driver over 24 hours, together with 40mgs of Midazolam. This medication was prescribed at 9.25 a.m. (9:25) and was administered with the sole intention of relieving [Mrs Devine’s] significant distress, anxiety and agitation, which were clearly very upsetting for her. I also prescribed Hyoscine to be given when required, to dry any chest secretions, but in fact it did not prove necessary to administer this. At this point it was clear that [Mrs Devine’s] renal function had deteriorated markedly, superimposed on her dementia, and she was now dying. The Fentanyl patch was removed a little later.”
During the 2009 FtP hearing, Dr Barton stated:
“[Mrs Devine] was halfway down the main corridor of the ward, hanging on to the bars and it was impossible for any of them to move her … [chlorpromazine was a] major tranquiliser, sedative. She was not safe standing there in the corridor. She needed to be in her bed, and it was going to take a major tranquiliser to peel her off the wall and get her into her own room … I suspected, her renal function had deteriorated quite quickly and quite markedly, and was probably contributing to the end stage dementia state that she was in. I did not think that it was related to the fentanyl. I thought that the fentanyl was not doing anything to make it better … [Although no active sign of pain] I wanted the midazolam. I needed the sedation and the anxiolytic properties of the midazolam in order to calm her down once the chlorpromazine wore off, and I was minded to continue an equivalent amount of diamorphine to replace the fentanyl dose that she had been having … I understood that the equivalence of the fentanyl was 90 mg of morphine in 24 hours, so using my conversion factor which was to halve it, the equivalent in diamorphine in 24 hours would be 40. I also knew that when you took the fentanyl patch off the level of fentanyl in the blood stream slowly reduced.”
On 19 November, the ‘Contact Records’ found in the hospital records note: “social services informed to close the case. Mulberry also informed.”
Panel comments – 8
- 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 she made the decision to prescribe diamorphine and midazolam.
- The Panel notes that Mrs Devine was an opioid-naïve patient with renal failure; however, she was commenced on a high dose of diamorphine.
- The Panel also notes that when diamorphine was administered, fentanyl would still have been pharmacologically active in Mrs Devine's system despite the patch having been removed.
- There are no clinical records to confirm on what basis Dr Barton prescribed diamorphine.
- There are no clinical records to confirm the rationale for the dose of diamorphine. There are no records to confirm that diamorphine was clinically indicated.
On 20 and 21 November, the syringe driver was recharged at 07:35 and 07:15 respectively. On 21 November, Mrs Devine died on Dryad Ward at Gosport War Memorial Hospital at 20:30.