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

• In 1993, Wilfred Harrington was aged 88 and lived at home with his wife who provided him with full-time care.
  
• On 8 June 1993, Mr Harrington was admitted to Gosport War Memorial Hospital (‘the hospital’) for a two- to three-week period of rehabilitation and respite care.
  
• On 21 June, Mr Harrington was assessed by a physiotherapist, when he stood from his chair and walked 15 yards with a Zimmer frame and assistance. His admission was extended for a further two weeks.
  
• On 5 July, Mr Harrington was not mobile, needed a hoist for transfer and had lost one and a half stone. His admission was changed to a long stay.
  
• On 21 July, Mr Harrington died.
  

In 1993, Mr Harrington was living at home with his wife. He had congestive heart failure, a sacral sore and blistering on his legs and toes. He required care and assistance from his wife when washing, dressing and walking with his Zimmer frame. He had been experiencing a reduced appetite and some weight loss because his top teeth had been removed, making it difficult to chew his food.

On 3 June 1993, Dr Althea Lord assessed Mr Harrington in outpatients and wrote a letter to his GP, saying:

Dr Lord also noted Mr Harrington’s current medication to be frusemide, digoxin and enalapril.

On 8 June, Mr Harrington was admitted to Daedalus Ward at the hospital for a two- to three-week period of rehabilitation and respite care.

On admission, Dr Jane Barton recorded in the clinical notes: “Admission for respite care. Recent difficulty coping at home … Feeds himself, needs help with dressing … can’t wash unaided, blistering of legs and foot.” The medical records confirm that Mr Harrington was taking co-proxamol, although it is not clear precisely why this analgesic was prescribed. He required assistance with washing and dressing and had poor balance. He had a poor appetite and a tendency to suffer constipation and urinary incontinence. He also had blisters on both legs, and required assistance to settle at night. Mr Harrington was unsteady on his feet but could walk short distances with a Zimmer frame.

On 9 June, the nursing notes record: “Night. Very confused, fell out of bed 23.10 hours. Sustained grazing to both knees, dressing applied to left knee no further signs of injury visible. Accident form completed.”

On 16 June, the nursing notes record “skin flap observed at 3am, steristrips and dressing and bandage applied, accident form filled in”.

• The Panel has found no entries in the clinical notes after 8 June, until 17 June. The medical records indicate that Mr Harrington was not seen by any doctor during this period.
  
• On 9 June, Mr Harrington fell out of bed with no injury noted, and on 16 June injury requiring steristrips and a dressing occurred. The Panel has found no other details relating to the fall or injury in the nursing notes.
  

On 17 June, Dr Lord recorded in the clinical notes: “CCF not under control … daily [weights], U/Es Monday. See legs Monday.” Dr Barton requested that Mr Harrington be seen by the physiotherapist for “gentle mobilisation”.

On 20 June, the nursing notes record “catheterised”.

On 21 June, Dr Lord recorded in the clinical notes “catheter inserted … blisters now dry, grazed both knees, not stable, confused at night, Barthel 6. OT [occupational therapist] to see … to stay in further 2/52 [2 weeks].” Mr Harrington was also seen by the physiotherapist, who wrote in the clinical notes: “[Mr Harrington] stood from his chair unassisted but needed steadying when standing. He walked with his Zimmer frame about 15 yds but tired and stiff his legs giving way. He would not be safe to walk unaccompanied and the moment.”

On 25 June, Dr Barton recorded in the clinical notes that Mr Harrington “has become poorly over the last four hours, weak, confused and swollen penis [illegible], basal creps, needs metolazone today. U’s and E’s this pm deterioration in renal function”. Dr Barton prescribed morphine oral solution 10 mg (5 ml) every six hours “if in pain”. However, this prescription was not administered.

• The Panel has found no document in the medical records to confirm Dr Barton’s rationale for prescribing morphine oral solution on 25 June.
  

On 28 June, the nursing notes record: “not so well this morning … has back pain. [Seen by] Dr Barton left leg and foot inflamed. Commenced antibiotics and Co-Dydramol for pain. To continue to record daily weight if well enough.”

Dr Barton prescribed co-dydramol every six hours. This prescription was administered once on 28 June at 09:15, and twice on 2 July at 13:30 and 18:00.

On 3 July, the nursing notes record that Mr Harrington fell out of bed with no apparent injuries noted. One dose of co-dydramol was administered at 09:00.

• The Panel has found no further details relating to the fall on 3 July.
  
• The Panel has found no entries in the clinical notes after 25 June, until 5 July.
  

On 5 July, Dr Lord recorded in the clinical notes that Mr Harrington was not mobile, needed a hoist for transfer and had lost one and a half stone between 10 June and 5 July. The next day, Mr Harrington’s wife agreed to a long-stay bed.

• The Panel has found no document in the medical records to confirm why Mr Harrington had become immobile by 5 July.
  
• Save for one entry on 6 July to confirm Mr Harrington’s wife’s agreement to a long stay, the Panel has found no entries other than bowel records and recordings of dressing changes in the clinical notes after 5 July, until 20 July. The medical records indicate that Mr Harrington was not seen by any doctor during this period.
  
• The nursing care plans indicate that during this period the nursing staff continued to monitor and treat Mr Harrington’s sacral sore, elbow, grazed knees, constipation, catheter and blisters on the legs, which were noted to be healing well on 13 and 21 July. Regular weight loss monitoring effectively ended on 5 July, with one further entry on 13 July of nine stone. Assistance with washing and dressing continued until 9 July when the notes record that thereafter Mr Harrington required bed baths. 
  
• The Panel has not found any record to confirm why nursing staff stopped monitoring Mr Harrington’s weight.
  

On 19 July, Dr Barton prescribed morphine oral solution 10 mg (5 ml) every six hours “if in pain”, and co-dydramol every six hours.

• The Panel has found no document in the medical records to confirm Dr Barton’s rationale for prescribing morphine oral solution on 19 July.
  

On 20 July, the next entries appear in the nursing notes and care plans. The nursing notes record “contracted and painful left leg” and “seen by Dr Barton X-ray of right hip requested”. The care plans record “unable to tolerate any attention to arms or legs”.

At 16:30, the nursing notes further record “X-ray shows fracture of the right femur. Dr Barton and Dr Lord discussed. Both agree patient too ill for operation. To have [morphine oral solution] 20mg orally and bed rest”. Between 11:25 and 23:45, three separate doses of morphine oral solution – 10 mg, 20 mg and 20 mg – and one dose of co-dydramol were administered to Mr Harrington.

• The medical records indicate that, prior to 5 July, Mr Harrington had been, to some extent, mobile. He had walked with a Zimmer frame and assistance, and was washing and dressing himself with assistance on a daily basis. The Panel has not found any document in the medical records to confirm the basis and rationale for the decision on 20 July that Mr Harrington was not fit for surgery.
  

On 21 July, the radiology report stated: “PELVIS:… No fracture. No significant degenerative change for age is present and the remainder of the bony pelvis is normal … CHEST: … heart is not significantly enlarged and no gross pulmonary abnormality is shown.”

• Given the content of the radiology report, it is not clear on what basis Dr Lord and Dr Barton reached a misdiagnosis that Mr Harrington had fractured his right femur the previous day; nor is it clear from the clinical notes whether Dr Barton or Dr Lord were aware of the radiology report on 21 July.
  
• The Panel has not seen any record of any further review by Dr Lord.
  

On 21 July, the nursing notes record “painful on moving may require analgesia later today”. Morphine oral solution 20 mg was administered at 06:10. His prescribed oral drugs were omitted at 08:00 as he was unrousable.

Dr Barton recorded in the clinical notes: “Developed contractures of arm and legs this week. Severe pain in hip yesterday. X-ray [illegible]. Condition continues to deteriorate. For sc analgesia. All nursing care.”

The drug chart confirms that Dr Barton prescribed a subcutaneous infusion of diamorphine 40 mg, hyoscine 200 micrograms and midazolam 20 mg per 24 hours.

The nursing notes also record: “X-ray report … no fracture. Seen by Dr Barton to commence syringe driver for pain and chestiness. Becoming increasingly breathless. Syringe driver set up at 14.30 hours”.

A syringe driver containing diamorphine prescribed at a rate of 40 mg per 24 hours, hyoscine at 200 micrograms per 24 hours, and midazolam at 20 mg per 24 hours was commenced.

• The Panel has seen no documents in the medical records to confirm why Mr Harrington had developed contractures. The Panel observes that there are no entries in the clinical notes after 5 July, until 21 July.
  
• The Panel notes that there was a misdiagnosis of a fracture on 20 July, which appears to have led to the initiation of the use of opioid analgesic. The Panel has not seen any document in the medical records to confirm that following the result of the X-ray Mr Harrington’s assumed fracture was clinically reviewed.
  
• The nature and extent of Mr Harrington’s “chestiness” and breathlessness noted on 21 July is not clear from the medical records. There is no cardiac or gross pulmonary abnormality reported on the chest X-ray on 21 July.
  
• The Panel has not seen any document in the medical records that gives any explanation for the nature, location and degree of pain noted on 21 July.
  
• The Panel has not found any document in the medical records to show that diamorphine, midazolam and hyoscine were clinically indicated on 21 July.
  
• The Panel has not found any document in the medical records to confirm Dr Barton’s rationale for prescribing diamorphine, midazolam and hyoscine on 21 July.
  
• The Panel notes the prescribing of diamorphine, hyoscine and midazolam in high doses. The dose of diamorphine administered on 21 July was approximately double the equivalent dose of morphine oral solution. No consideration was given to the fact that Mr Harrington was unrousable two hours after the dose of oral morphine on 21 July.
  
• At the time of Mr Harrington’s admission, accountability was an integral part of nursing practice. Nurses were accountable for their actions, and inactions, at all times. The relevant nursing professional codes of conduct and standards required nurses to: scrutinise a prescription in the interests of safety; question any ambiguity in the prescription; refuse to administer a prescription where they believed such an action was necessary; and report to an appropriate person or authority any circumstances that could jeopardise the standards of practice or any concern about health services within their employing Health Authority or Trust. The codes and guidance made it clear that to silently tolerate poor standards is to act in a manner contrary to the interests of patients or clients, and contrary to personal professional accountability. Nurses were required to promote and protect the interests of patients.
  
• The Panel has not seen any document to confirm that the nurses consulted the British National Formulary (BNF) guidance or Wessex guidelines² to scrutinise the diamorphine, hyoscine and midazolam prescription or refused to administer the drugs at any time.
  
• The relevant nursing codes of conduct and standards required nurses to be able to justify any actions taken and to be accountable for the actions taken when administering or overseeing the administration of drugs. The Panel has not seen any document in the medical records that shows the nurses’ rationale for commencing the prescription of diamorphine, hyoscine and midazolam.
  
• The Panel has not seen any document to show that the nurses were provided with any written guidance from the doctors, consultants or the Trust about when to commence the administration of diamorphine, hyoscine and midazolam.
  

The next entry on 21 July records that Mr Harrington’s condition deteriorated rapidly and he died at 15:00.

• Mr Harrington died 30 minutes after the first and only dose of diamorphine, midazolam and hyoscine.
  
• At the time of Mr Harrington’s admission, guidance from the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) and the Royal College of Nursing (RCN) (see Bibliography in Appendix 2) emphasised the requirement for nurses to work in an open and cooperative manner with patients and their families. In this regard, the Panel has seen no documents in the clinical records to confirm that nurses engaged in any adequate ongoing treatment or end of life care discussion with Mr Harrington’s family.
  
• At the time of Mr Harrington’s admission, the UKCC guidance required nurses to carry out a comprehensive assessment of the patient’s nursing requirements, and devise, implement and keep under review care plans. The UKCC guidance also required nurses to create and maintain medical records in order to provide accurate, current, comprehensive and concise information concerning the condition and care of the patient. Such records would include: details of observations, problems, evidence of care required, action taken, intervention by practitioners, patient responses, factors that appeared to affect the patient, the chronology of events, and reasons for any decision. These records would provide a baseline against which improvement or deterioration could be judged. Among other elements of care, “Through their role in drug administration nurses are in an ideal position to monitor the drugs progress, reporting responses and side effects”. In this regard, the Panel found a lack of detail in Mr Harrington’s daily nursing notes and care plans. The nursing notes and care plans seen by the Panel were scanty, lacked biographical data, were not personalised to the patient’s needs and contained missing entries for entire days. For example, the ‘Assistance to Settle at Night’ care plan lacked entries for 28 of the days that Mr Harrington was admitted. There was nothing in the care plans to document Mr Harrington’s confusion, to take account of his capabilities, or to identify his likes, dislikes and preferences. The Panel has found no pain charts or pain management plans in Mr Harrington’s medical records. It is not clear to the Panel how Mr Harrington’s pain and the effectiveness of any analgesia was adequately monitored.
  
• The Panel has not seen any nutrition or fluid charts among Mr Harrington’s medical records. Fluid and nutritional intake is an important part of the clinical picture.
  
• Overall, the Panel found a lack of detail in Mr Harrington’s clinical and nursing notes.