Chapter 3: The experience of patients and families on the wards

In 1998, Arthur Cunningham was aged 79. He was a widower. He was diagnosed with Parkinson’s disease, dementia, reactive depression, diet controlled diabetes and myelodysplasia; he also had an old pelvic injury. Mr Cunningham was experiencing hallucinations and dystonic movements caused by his medication. His mobility was poor and although he could walk he also used a mobility scooter and wheelchair to aid mobilisation. Historically, Mr Cunningham had lived in supported accommodation but by June 1998 he was living in a nursing home and was a regular visitor to Dolphin Day Hospital, Gosport War Memorial Hospital, under the care of Dr Althea Lord.

On 21 July, Mr Cunningham was admitted to Mulberry Ward at Gosport War Memorial Hospital (’the hospital’). On 28 August, he was discharged to his nursing home. On 21 September, he was readmitted to the hospital for active treatment of a sacral sore. He was expected to return to his nursing home. On 26 September, Mr Cunningham died.

On 21 July 1998, Mr Cunningham was admitted to Mulberry Ward at the hospital because renovations were taking place at his nursing home. On 27 August, Dr Lord reviewed Mr Cunningham and noted that he was fit for discharge the next day. On 28 August, Mr Cunningham was discharged to his nursing home. By 18 September, Mr Cunningham had “settled well” into the nursing home.

On 21 September, Mr Cunningham was reviewed by Dr Lord at Dolphin Day Hospital. She noted a “large necrotic sacral ulcer which was extremely offensive”. Dr Lord admitted Mr Cunningham directly to Gosport War Memorial Hospital for active treatment of his sore. His nursing home was requested to keep his place open for a period of two to three weeks as he was expected to return there. Dr Lord noted “prognosis poor”. She prescribed morphine oral solution 2.5–10 mg, as required, four hourly, to be administered prior to dressing his sacral sore. Mr Cunningham was administered 5 mg of morphine oral solution at 14:50 and 10 mg at 20:15.

Dr Jane Barton, clinical assistant, also recorded in the clinical notes: “Transfer to Dryad Ward. Make comfortable. Give adequate analgesia. I am happy for nursing staff to confirm death.” Dr Barton prescribed diamorphine 20–200 mg, midazolam 20–80 mg, hyoscine 200–800 micrograms, subcutaneously, as required, over 24 hours. At 23:10, 20 mg of diamorphine and 20 mg of midazolam were administered by continuous subcutaneous infusion.

Dr Barton recorded:

In relation to the prescription for diamorphine and midazolam, Dr Barton stated in an interview with Hampshire Constabulary in April 2005:

In 2009, Dr Barton told the General Medical Council (GMC) Fitness to Practise (FtP) hearing:

On 22 September, at 20:20, 20 mg of diamorphine and 20 mg of midazolam were administered subcutaneously.

On 23 September, Mr Cunningham had “become chesty overnight”. The syringe driver set up the evening before was paused and hyoscine added; there is no record on the drug chart that any remaining drug was discarded. At 09:25, the syringe driver was restarted with diamorphine 20 mg, midazolam 20 mg and hyoscine 400 micrograms to be administered over 24 hours. At 13:00, the clinical records note that Mr Cunningham’s son was “very angry that syringe driver has been commenced … now fully aware that [Mr Cunningham] is dying and needs to be made comfortable”. The drug chart further records “discarded” on the 09:25 diamorphine dose and, at 20:00, the administration of 20 mg of diamorphine, 60 mg of midazolam and 400 micrograms of hyoscine was commenced.

In her statement to the police, Dr Barton said: “I anticipate that Mr CUNNINGHAM’S agitation might have been increasing, hence the increase in the level of Midazolam.”

During the FtP hearing, Dr Barton stated:

The clinical notes record: “Became a little agitated at 23:00hrs, syringe driver boosted with effect. Seems in some discomfort when moved, driver boosted prior to position change.” The notes further record that Mr Cunningham’s catheter was draining but the urine was very concentrated.

On 24 September, Mr Cunningham was in pain when attended to and the diamorphine, midazolam and hyoscine were increased at 10:55. He was commenced on diamorphine 40 mg, midazolam 80 mg and hyoscine 800 micrograms by syringe driver over 24 hours. Dr Barton noted: “Remains unwell. Son has visited again today and is aware of how unwell he is. sc analgesia is controlling pain just. I am happy for nursing staff to confirm death.”

In her statement to the police, Dr Barton said:

During the FtP hearing, Dr Barton said that nurses had informed her that Mr Cunningham was becoming tolerant of the diamorphine and she needed “to increase the dose a little bit to give him the same level of comfort”.

On 25 September, Dr Sarah Brook, a GP in Dr Barton’s practice who assisted at the hospital, recorded in the clinical notes: “remains very poorly on syringe driver, for TLC”. Dr Barton wrote another prescription increasing the ranges for diamorphine to 40–200 mg, midazolam 20–200 mg and hyoscine 800 micrograms–2 gm. The drug chart records that, at 10:15, diamorphine 60 mg, midazolam 80 mg and hyoscine 1,200 micrograms were administered by syringe driver over 24 hours.

In her statement to the police, Dr Barton said:

During the FtP hearing, Dr Barton stated that she did not see Mr Cunningham on this day.

On 26 September, the drug charts confirm that at 11:50 diamorphine 80 mg, midazolam 100 mg and hyoscine 1,200 micrograms were given by syringe driver over 24 hours. The clinical records note that, on 26 September: “[Mr Cunningham’s] condition continued to deteriorate [and he] died 23:15.”

In her police interview, Dr Barton stated:

During the FtP hearing, Dr Barton confirmed that 26 September was a Saturday, that she did not see Mr Cunningham on this day and that she assumed he would have been seen by the duty doctor.

21 September 1998

• The Panel has not seen any document in the clinical records to confirm Dr Barton’s rationale for prescribing diamorphine and midazolam at this stage.
  
• The Panel notes that Mr Cunningham was opioid naïve.
  
• The Panel notes the wide dose range of diamorphine which was prescribed in a patient who had renal impairment.
• Dr Barton did not record the explanations she provided to the police or to the FtP hearing in Mr Cunningham's clinical notes at the time of her assessment.

23 September 1998

• The Panel has not seen any document in the clinical records to confirm the rationale for the three-fold increase in the dose of midazolam commenced at 20:00 on 23 September.
• Dr Barton did not record the explanations she provided to the police or to the FtP hearing in Mr Cunningham's clinical notes at the time of her assessment.
• The Panel notes that the 23:00 boost was not recorded in the drug chart. The Panel has not seen any record to confirm the magnitude of the increase in dose.
  

24 September 1998

• The Panel has not seen any document in the clinical records to confirm the rationale for the two-fold increase in the dose of diamorphine and hyoscine and the one-third increase of midazolam.
  
• Dr Barton did not record the explanations she provided to the police or to the FtP hearing in Mr Cunningham's clinical notes at the time of her assessment.

25 September 1998

• The Panel notes that there was an error in the prescribed dose of hyoscine, which was written as mg rather than mcg (micrograms).
  
• The Panel has not seen any document in the clinical records to confirm the rationale for the increase in the prescribed dose range of diamorphine, hyoscine and midazolam.
• Dr Barton did not record the explanations she provided to the police in Mr Cunningham's clinical notes at the time of her assessment.

26 September 1998

• The Panel has not seen any document in the clinical records to confirm the rationale for the increase in diamorphine and midazolam.
• Dr Barton did not record the explanations she provided to the police in Mr Cunningham's clinical notes at the time of her assessment.

General comments

• The Panel has not seen any document in the clinical records to confirm that nurses engaged in any adequate end of life care discussion with Mr Cunningham’s family.
  
• The Panel feels that in light of the reported anxiety of Mr Cunningham's son, an appointment with a consultant should have been made. 
• The Panel has not seen any document to confirm that nurses treating Mr Cunningham challenged the proactive and repeated high and wide dose range prescription of diamorphine, midazolam and hyoscine.
  
• The Panel has not seen any document to show that nurses consulted the British National Formulary (BNF) guidance or the Wessex guidelines⁶ to scrutinise the doses; nor did they question any of the consultants, doctors or the pharmacist at the hospital in respect of the prescription and doses.
  
• The Panel has not seen any nursing document in the clinical records to show the reason or rationale for the decision to commence and continue the use of diamorphine and midazolam.
  
• The Panel has not seen any nursing document in the clinical records to show that nurses consulted the BNF guidance, the Wessex guidelines, any doctor or the pharmacist when commencing the administration of diamorphine and midazolam.
  
• The Panel has not seen any document to show that nurses were provided with any written guidance from the doctors, consultants or Portsmouth HealthCare NHS Trust on when to commence the administration of diamorphine and midazolam.
  
• The care plans seen by the Panel were limited in detail, were not personalised to the patient’s needs and did not take account of Mr Cunningham’s capabilities, likes, dislikes and preferences.
  
• The Panel found no pain charts or pain management plans in Mr Cunningham’s clinical records. It is not clear to the Panel how Mr Cunningham’s pain and the effectiveness of any analgesia were to be adequately monitored.
  
• The Panel has not seen any fluid charts or nutrition plan among Mr Cunningham’s clinical records. Fluid and nutritional intake was an important part of the clinical picture. Diamorphine and midazolam could impair the ability to eat and drink.
  
• The Panel has not seen any document in the clinical records to show that the nurses treating Mr Cunningham understood or took into account these possible side effects of morphine when noting Mr Cunningham’s condition.