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

• The Panel has found nothing in the medical or other records it has examined which undermines the startling account of Pauline Spilka. It is an account which is confirmed through a range of case studies the Panel has prepared in order to convey the experience of patients as recorded in their medical records while properly not publishing these records.
  
• The Panel has described an overall picture of nursing care which is disquieting when assessed against the standards prevailing at the time.
  
• The Panel has not applied a standard of perfection when comparing what the records show happened at the hospital with the formal standards and expectations. The Panel acknowledges the bravery shown by the nurses when they challenged the prescribing practice in 1991.
  
• The Panel also found a very poor standard of record keeping, including poor recording of the clinical justification for the commencement of drugs in relation to the patients’ presenting condition.
• The medical records seen by the Panel confirm Dr Jane Barton’s role in determining how the drugs were prescribed and administered over her 12-year period as clinical assistant. Dr Barton was central to:
  

• providing an initial assessment and diagnosis of the patient
  

• prescribing any medication required
  

• liaising with the nursing teams
  

• providing day-to-day medical management of the patients and assessing their progress
  

• the standard of documentation in the medical records at the time
  

• decisions about discharge.
  

• The Panel has found that, often at the same time as patients were admitted to the wards with a plan to return home with the support of the family following treatment, the clinical notes were stating, “I am happy for my staff to confirm death”. 
• This chapter and its case studies have highlighted the shortcomings in the nursing care provided at the hospital as well as the excesses in the administering of drugs. The circumstances in which this happened can only be explained by looking at what the documents have revealed about the respective roles of the consultants and the clinical assistant, in conjunction with the nurses and the pharmacist. These are summarised in the following findings. By ’findings’ the Panel reveals that which is found in the documents provided.  

Finding One: Responsibility of nurses to their patients

The nurses on the wards were not responsible for the practice of prescribing. They were responsible for administering the drugs, including via syringe drivers. The pattern of deaths as evidenced in Chapter 2, and the experience of patients as shown by the medical records highlighted in this chapter, show that the nurses should have seen the link between their administration of the drugs and the shortening of life which followed. Nurses had a responsibility to challenge prescribing where it was not in the interests of the patient; the records show that the nurses did not discharge that responsibility and continued to administer the drugs prescribed.

Finding Two: Responsibility of Dr Barton as clinical assistant

Over a 12-year period as clinical assistant, Dr Barton was responsible for the practice of prescribing which prevailed on the wards. 

Finding Three: Responsibility of the consultants

Although the consultants were not involved directly in treating patients on the wards, the medical records highlighted in this chapter show that they were aware of how drugs were prescribed and administered but did not intervene to stop the practice. 

Finding Four: Responsibility of the pharmacist

The documents record both the quantities of opioids used on the wards and the fact that the patients admitted were not 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 should have been evident at the time.

Finding Five: Nature of communication with families, including complaints

The Panel notes that in a few cases there were well-recorded discussions of treatment plans for individuals. However, for the most part, the records show snippets of brief exchanges characterised by ambiguous phrases reflecting the underlying attitude: the families were marginalised by the professional staff.