Chapter 3: The experience of patients and families on the wards
How patients were treated: the roles and responsibilities of the clinical assistant
Key to looking at what happened at the hospital is an understanding of the roles and responsibilities of Dr Barton as the clinical assistant and how she discharged them.
Dr Barton took up her post as clinical assistant in the hospital on 1 May 1988 and she remained in this role for 12 years until tendering her resignation in April 2000 (NHE000212, p1).
This was a new post of five sessions a week, worked flexibly to provide 24-hour medical cover. The job description makes it clear that the post-holder must visit the wards on a regular basis, be available on call as necessary and fulfil the following requirements:
“⦁ To be responsible for the day to day Medical Management of the patients
⦁ To prescribe, as required, drugs for the patients under the care of the Consultant Physicians in Geriatric Medicine
⦁ To be available when required to advise and counsel relatives
⦁ To be responsible for liaison with the General Practitioners with whom the patient is registered and with other clinicians and agencies as necessary.” (GMC101022, pp18–19)
Dr Barton had previously worked as a GP in Dorset and from 1980 in Gosport. On her application for the post, she described herself as a “minimum full timer”, working 20 hours a week on practice commitments (GMC101022, pp22–3). Dr Barton’s practice was local to the hospital and she had around 1,500 patients on her list (HCO110482, p1).
The documents seen by the Panel show that there were no other applicants for the post (GMC101022, p24).
In NHS practice, the title ‘clinical assistant’ refers to a doctor, usually a GP, who provides care at a level below that of consultant. Except in designated GP beds, a consultant retains overall responsibility for the patient’s care, but delegates some elements of day-to-day care according to their assessment of the capability of the clinical assistant.
The documents reveal how Dr Barton conducted herself once appointed. The Panel has looked at what Dr Barton herself said, at what others said about her and at what the medical records show.
Chapter 6 describes how the General Medical Council (GMC) subsequently examined Dr Barton’s conduct. In those proceedings, Dr Barton said in March 2002 that of her five sessions as a clinical assistant, one and a half were allocated to partners in her GP practice to cover the out-of-hours aspect of the job. This left her with three and a half clinical assistant sessions and 48 long-stay geriatric beds. Dr Barton would subsequently explain in her statement to Hampshire Constabulary that, for the period up to 1998, she was engaged for four sessions each week, one of which was allocated to her GP partners for out-of-hours cover. According to Dr Barton, this reflected a change in her working conditions (HCO110482, p1).
Dr Barton described how she would visit the two wards, Dryad and Daedalus, at 7.30am, before arriving at her surgery at 9.00am. Towards the end of her period as clinical assistant, she would return at lunchtime most days in order to admit patients or to write up charts or see relatives; and, she said, she would quite often return at around 7.00pm, particularly to see relatives who were visiting in the evening.
Outside these hours, Dr Barton said:
“The nursing staff would therefore ring me either at home or at my GP surgery to discuss developments or problems with particular patients. In the event that medication was to be increased even within a range of medication already prescribed by me, it would be usual for nursing staff either to inform me of the fact that they considered it necessary to make such a change, or they would inform me shortly thereafter of the fact that the increase had been made.” (HCO110482, p1)
Dr Barton’s own statements confirm that, on a day-to-day basis, she was the sole doctor available for the patients: “Mine was the medical input” (GMC101057, p22). When asked about responsibility for prescribing and “would it always be you?”, Dr Barton’s reply was, “It was generally me” (p24).
The role of the clinical assistant in practice is confirmed by the following descriptions provided by nurses at the hospital:
- Nurse Siobhan Collins: “I cannot recall anyone making criticisms of her during my time at the Hospital. I found that I never had any problem getting hold of her when I called, and she was always quite happy to be contacted. Dr Barton seemed very conscientious. She was always very pleasant, and was respectful of the views of nurses.” (MDU100001, p6)
- Nurse Fiona Walker: “I never had any difficulty about contacting her for advice concerning a patient if that was necessary.” (MDU000002, p3)
- Sister Gillian Hamblin: “Quite simply, she had so much to do that it was not possible for her to attend to all of her clinical duties in seeing and assessing, and indeed caring for the patients, and then making comprehensive notes about her reviews. In my view, the quality of her care was not compromised or limited, but given the constraints on time, she had no alternative but to keep her notes more limited in order for her to cope.” (MDU000004, p7)
The medical records seen by the Panel confirm Dr Barton’s role in determining how 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.
Dr Barton’s role is very evident from quotations from families and from a range of case studies, including Case Studies 3 and 4.
A son recollected his mother’s experience:
“In fact [the doctor] said to me ‘You know your mother is very unwell and we would like your permission to administer the necessary drugs to assist her through at the end’. Naturally, I was very distressed by this, and tearful, and expressed my amazement that I was being asked to sanction what appeared to be euthanasia. When we left the meeting room, [the doctor] commented to the nursing staff ‘we’ve got another weeper here’.”