Chapter 3: The experience of patients and families on the wards
The consultants were responsible for the care given to their patients even when some elements of it were delegated to another doctor, in this case the clinical assistant. They were responsible for supervising her practice to the extent that they judged it necessary to ensure that care was being given safely and effectively. Either supervision was not carried out effectively or the consultants approved of the care given by the clinical assistant.
How patients were treated: the roles and responsibilities of the pharmacists
Pharmacy services to Gosport War Memorial Hospital were provided under a service-level agreement with Portsmouth and South East Hampshire Health Authority. This included the procurement and supply of medicines required, together with advice on their use, security and custody. The contract was managed by the senior, chief pharmacist, and a second pharmacist provided the service. This arrangement appears broadly to have followed standard NHS pharmacy practices for remote non-acute hospitals at the time (DOH800198, pp1–21).
Portsmouth Hospitals NHS Trust and its chief pharmacist therefore had overall responsibility for pharmacy services at the hospital. The chief pharmacist was responsible for oversight of the procurement, control, storage and distribution of drugs for all Portsmouth hospitals, ensuring that there were procedures in place to maintain adequate and safe stocks in each ward area and that drugs were stored securely.
The chief pharmacist was also responsible for ensuring that advice and support were provided to ward staff; for training and development of the hospital’s pharmacists; and, with the support of clinical staff and the Drugs and Therapeutics Committee, for ensuring that prescribing guidelines were adhered to and that the drug charts being used in the hospital were fit for purpose, safe and in line with national policy and guidance.
The chief pharmacist was a key member of the Trust’s Drugs and Therapeutics Committee, which had broad oversight of prescribing policy and practice, including the appropriateness and affordability of new drugs introduced in the hospital.
At one stage the hospital had its own pharmacy department located within the outpatients department. It had been well established for many years and was staffed several days a week by a pharmacist from Portsmouth Hospitals NHS Trust, who made ward visits throughout Gosport War Memorial Hospital, including checks on controlled drugs. This facility was lost in the 1994–96 redevelopment and the on-site pharmacy was replaced by a remote service (RCN000037, pp1–3).
Subsequently, medicines were supplied to wards at the hospital in locked boxes directly from Portsmouth Hospitals NHS Trust pharmacy, against signed orders from a senior nurse on each ward. In line with universal good practice in the NHS, there was an additional system for signed orders, secure transit, and signed handover and receipt on the wards of controlled drugs. Pharmacist visits to the hospital continued twice a week and included checks on ward stocks and examination of patients’ drug charts (HCO109728). The system was primarily aimed at maintaining adequate supplies, but there was also a mechanism for raising concerns. Jean Dalton, a community services pharmacist, said:
“Daedalus ward would have been visited on a Thursday and that visit involves looking through the medical charts and checking for supplies and just generally checking whether things are appropriate … as I go through the charts I would also check for relevance of the medicines that are prescribed.” (HCO109728, pp2–3)
The route for raising concerns was via the senior nurse to the clinical assistant or consultant. There was no systematic process for a review of prescribing. In the report of its investigation of Gosport War Memorial Hospital and Portsmouth Hospitals NHS Trust, the Commission for Health Improvement (CHI) described:
“… a remote relationship between the community hospitals and the main pharmacy department at Queen Alexandra Hospital … There were no systems in place in 1998 for the routine review of pharmacy data which could have alerted the trust to any unusual or excessive patterns of prescribing although the prescribing data was available for analysis … it is clear that had adequate checking mechanisms existed in the trust, this level of prescribing would have been questioned.” (CQC100951, p33)
The CHI report, using the Trust’s own medicines usage data, noted the excessive use of diamorphine and midazolam, which reached a peak in 1998/99. Over that period Dryad, Daedalus and Sultan wards used 1,617 doses of diamorphine and 1,650 doses of midazolam.
Among the documents reviewed by the Panel are references to the involvement of the pharmacist on the wards; for example, this statement from Sister Hamblin:
“The Pharmacist for the Hospital, Jean Dalton, attended on the Ward each Monday, reviewing all the drug charts and the drug stock. She would give advice and guidance, but I do not believe she ever raised criticism, or that concern was ever expressed by her about the arrangements for prescribing in the way that we had adopted.” (MDU000005, p2)
The documents record both the quantities of opioids used on the wards and the fact that the patients admitted were not in the main assessed as requiring palliative or end of life care. There is no evidence available to the Panel to suggest that either the pharmacists or Portsmouth HealthCare NHS Trust’s Drugs and Therapeutics Committee challenged the practice of prescribing which would have been evident at the time.
Communication with families, including informal complaints
Communicating clinical decisions to both patients and families is a key aspect of care. The available documents do not provide a complete record of conversations involving patients, their families and the staff at the hospital. The Panel has compiled a number of case studies which include references illustrating the nature of the communication that took place. Case Study 6 is one such example.