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

• In 1999, Peggy Coates was aged 76 and lived at home with her son.
  
• On 3 April 1999, she had a cerebral infarct (stroke) and was admitted to Queen Alexandra Hospital.
  
• On 2 June, she was admitted to Daedalus Ward at Gosport War Memorial Hospital (‘the hospital’) for rehabilitation and intensive nursing input.  
  
• On 15 July, Mrs Coates died.
  

In 1999, Mrs Coates lived at home with her son. Her husband had recently died. She had a history of hypertension, heart failure, osteoporosis and non-insulin dependent diabetes mellitus which was controlled by tablets and diet. She also had depression. Her stroke had been complicated by epileptic fits.

On 2 June 1999, Mrs Coates was transferred from Queen Alexandra Hospital to Daedalus Ward at Gosport War Memorial Hospital. The records confirm that on transfer she had a diabetic diet and was able to feed herself. She wore pads for double incontinence, was immobile and required two people to transfer her from her bed to a chair. She was put into bed by hoist. Mrs Coates was also described as having confusion at times and experiencing a great deal of back pain. There had been variable success in controlling her pain and her diabetes was unstable. The only analgesia prescribed by Queen Alexandra Hospital was paracetamol. The initial plan was for Mrs Coates to return home, supported by her family. However, she was admitted to Daedalus Ward for rehabilitation and intensive nursing input.

On admission, Mrs Coates was assessed by Dr Jane Barton, clinical assistant, who noted: “Please make comfortable … I am happy for my staff to confirm death.” The nursing notes record: “slightly confused no hearing aid. Pt is compliant. Not in pain at the moment.” Dr Barton prescribed paracetamol 500 mg.

• It is not clear to the Panel why Dr Barton noted on Mrs Coates’s admission to the hospital: “Please make comfortable” and “I am happy for my staff to confirm death”. According to the records, the plan was that Mrs Coates would be rehabilitated and return home.
  

On 3 June, Dr Barton noted: “had a brief convulsion this am … seems brighter now.” The nursing notes record: “Dr Barton to commence … catheterisation if [Mrs Coates] agrees.” Later that day, Mrs Coates was catheterised.

On 4 June, the nursing notes record: “fit after having a bath. Last for approx. 30 seconds. Limbs shaking recovered well remained in bed.”

On 5 June, the nursing notes record: “not so well this morning. Son seen care discussed appreciates that condition may worsen.”

On 7 June, Dr Barton noted “epilepsy -2 seizures since admission” and prescribed morphine oral solution 10 mg in 5 ml (2.5–5 ml), four hourly, as required, and diamorphine 20–200 mg, hyoscine 200–800 micrograms and midazolam 20–80 mg all to be administered subcutaneously over 24 hours. The drugs were not administered. The nursing care plan records: “2 paracetamol given for a headache prior to bedtime. Pt settled and slept well. Has woken up with a headache. Declined analgesia until after breakfast.”

• The Panel has found no document in the clinical records to confirm Dr Barton’s rationale for prescribing morphine oral solution and the subcutaneous infusion of diamorphine, midazolam and hyoscine on 7 June.
  

On 13 June, the nursing care plan notes record “generalised pain analgesia given”. The drug chart confirms that between 11 and 20 June, co-codamol was administered four times daily, and twice on 21 June.

On 18 June, the nursing notes record: “22.20 requested Dr Briggs review pain relief due to headaches, neck aches and general discomfort.” On the same day, the clinical notes record: “persistent headaches and muscoskeletal pain. Little benefit from the use of Co-codamol. Try small starter dose of oral morphine solution 5mg/10mls.” Dr Michael Brigg prescribed morphine oral solution 2.5–5 mg (2.5–5 ml) four to six hourly, as required.

On 20 June, morphine oral solution 5 mg (2.5 ml) was administered at 18:15.

On 21 June, the clinical notes record: “headaches … complains of pain in both LLs calling out frequently.” The nursing notes record: “seen by Dr Lord commence Co-dydramol, Amitriptyline and lactulose. Bowels to be observed.” Dr Barton prescribed morphine oral solution 10 mg/5 ml, 2.5–5 mg four hourly as required, and diamorphine, hyoscine and midazolam subcutaneously over 24 hours. In addition she prescribed co-dydramol six hourly.

Co-dydramol was administered between 21 June and 2 July.

On 28 June, Dr Althea Lord, a consultant geriatrician, recorded in the clinical notes: “today pain in abdomen and back … oral morphine solution if very distressed.” The nursing care plan records: “03.25hrs administered 5mg/2.5mls of oral morphine solution due to patient awake distressed and informing staff of pain in left shoulder. Pt wished for analgesia. 07.15 no pain on movement this morning.” Morphine oral solution 5 mg was also administered at 16:00.

On 29 June, morphine oral solution 5 mg was administered at 03:25 and 14:30.

On 2 July, the drug chart indicates that Dr Barton prescribed morphine oral solution 5 mg (2.5 ml) four hourly between 06:00 and 18:00 and one dose of morphine oral solution 10 mg (5 ml) to be taken at 22:00. The drug chart further indicates that these doses were administered to Mrs Coates daily between 3 and 4 July.

On 5 July, the drug chart indicates that 5 mg (2.5 ml) of morphine oral solution was administered at 06:00. The clinical notes record that Mrs Coates was reviewed by Dr Lord, who noted “had some oral morphine solution over the w/e. Confusion. Varying sites of pain head and abdo … plan: try paracetamol for pain. Stop oral morphine solution.” The nursing notes record: “unaware when being attended not safe to give oral medication. Comfortable and appears pain free. General condition deteriorated over-night.”

• The Panel has not found any document in the clinical records to show that morphine oral solution was clinically indicated between 2 and 5 July.
  

On 6 July, the nursing notes record: “refused analgesia at 22:00 … headache this morning paracetamol given 06:55.”

On 9 July, the clinical notes record that Mrs Coates was assessed by Dr Barton, who noted “not too well … urine cloudy suggests UTI start amoxicillin. pain relief still a problem try transdermal.” The drug chart records that Dr Barton wrote a prescription for a fentanyl patch 25 mg, at 10:00 every three days, which was administered on 9 and 12 July and remained in place until 14 July.

• The Panel has not found any document in the medical records to confirm Dr Barton’s rationale for prescribing fentanyl on 9 July.
  
• The Panel has not found any document in the medical records to show that fentanyl was clinically indicated between 9 and 14 July.
  

On 12 July, the clinical notes record that Mrs Coates was reviewed by Dr Lord, who noted: “more settled on fentanyl. Not calling out. Not distressed … drinking … not stable enough for D just yet.” The nursing notes record: “Dr Lord, to continue with fentanyl patch.”

• It is not clear to the Panel what Dr Lord meant by “not stable enough for D just yet”.
  

The nursing care plan notes that Mrs Coates had eaten small amounts daily from the date of admission up to 13 July.

On the night of 13 July, the night staff were concerned about Mrs Coates, who had deteriorated and was in pain on movement. They called in the family and agreed to the commencement of a syringe driver. The pre-prescribed (from 21 June) syringe driver containing diamorphine 20 mg, midazolam 20 mg and hyoscine 400 micrograms over 24 hours was commenced at 07:45.

On 14 July, an untimed note from Dr Barton records: “marked deterioration during the day yesterday. Unrousable, [illegible], Cheyne-Stokes breathing overnight. SC analgesia started this am … I am happy for my staff to confirm death.”

The nursing notes record a further conversation with the family:

• The Panel notes that the clinical records appear to show the initiation of a diamorphine infusion in a patient with Cheyne–Stokes breathing.
  
• Cheyne–Stokes breathing is an abnormal breathing pattern which can be seen with opioid toxicity. The Panel notes that it might have been related to the use of the fentanyl patch.
  
• An alternative, because Dr Barton’s entry is untimed and the Panel has been unable to find any record of Cheyne–Stokes breathing in the nursing notes, is that the patient had Cheyne–Stokes breathing when reviewed by Dr Barton and that this was due to the additional subcutaneous diamorphine being administered at an excessive dose.
  
• It is not clear whether the fentanyl patch was removed before diamorphine was commenced on 14 July. There is no record to show that it was removed. Even if it had been, it would still have been pharmacologically active.
  
• The Panel has not found any document in the clinical records to show that diamorphine, midazolam and hyoscine were all clinically indicated on 14 July. The Panel notes that Mrs Coates was described on 13 July as “more settled on Fentanyl. Not calling out” and on 14 July as being “unrousable” and having Cheyne–Stokes breathing.
  
• The Panel has not found any document to show the rationale for commencing a subcutaneous infusion of diamorphine, midazolam and hyoscine on 14 July.
  

On 15 July, doses for each of the components of the syringe driver medication were doubled. At 09:15, a syringe driver containing diamorphine 40 mg, midazolam 40 mg and hyoscine 800 micrograms was commenced.

• The Panel has found no document to confirm the rationale for the administration and doubling of the dose of diamorphine, midazolam and hyoscine on 15 July.
  
• The Panel has not seen any document in the medical records to confirm that diamorphine, midazolam and hyoscine were clinically indicated on 15 July.
  

Mrs Coates died on 15 July at 17:30.

• The Panel notes that Mrs Coates died the day after the first and high dose of diamorphine.
  
• Paracetamol, co-codamol and co-dydramol were used initially and then variously until 9 July. A ‘starter dose’ of morphine oral solution was prescribed on 18 June. Morphine oral solution was variously administered between 18 June and 9 July. On 9 July, fentanyl was prescribed and used until 14 July. On 14 July, subcutaneous diamorphine, midazolam and hyoscine were then introduced and used until Mrs Coates’s death on 15 July.
  
• At the time of Mrs Coates’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, where believed necessary refuse to administer a prescription, 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 nurses consulted the British National Formulary (BNF) guidance or the Wessex guidelines³ to scrutinise the morphine oral solution, fentanyl, 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 to show the nurses’ rationale for commencing the prescription of morphine oral solution, fentanyl, diamorphine, hyoscine or 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 morphine oral solution, fentanyl, diamorphine, hyoscine or midazolam.
  
• At the time of Mrs Coates’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 Mrs Coates’s family.
  
• At the time of Mrs Coates’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 a nursing care plan. 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 appear 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 information in Mrs Coates’s daily nursing notes and care plan records. 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 19 of the days that Mrs Coates was admitted. There was nothing in the care plans that took account of Mrs Coates’s capabilities, likes, dislikes and preferences.
  
• The Panel found no pain charts or pain management plans in Mrs Coates’s medical records. It is not clear to the Panel how Mrs Coates’s pain and the effectiveness of any analgesia were adequately monitored.
  
• The Panel has not seen any nutrition or fluid charts among Mrs Coates’s medical records. Fluid and nutritional intake is an important part of the clinical picture.
  
• The specific plan of care for Mrs Coates is difficult to ascertain. It seems to have been to stabilise her diabetes and pain control. However, no plan appears to have been identified for pain control and there is no mention of psychological support/bereavement care, although she had recently lost her husband and was depressed.
  
• Overall, the Panel found a lack of detail in Mrs Coates’s clinical and nursing notes. The clinical notes contained entries on 13 days only and the nursing notes contained entries on 15 days only.