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Chapter 6: The General Medical Council

Findings of fact: Jean Stevens (Patient L)

6.152

The findings of fact for Jean Stevens who had been admitted to Daedalus Ward on 20 May 1999 were as follows (GMC100948, pp205–6, 239–41):

20 May 1999: Dr Barton prescribed 10 mg oramorphine in 5 ml, 2.5–5 ml

  • FtP found proved that there was insufficient clinical justification for such prescriptions.
  • Dr Barton admitted that the prescribing created a situation where drugs could be administered which were excessive to the patient’s needs.
  • FtP found proved that the prescribing was inappropriate.
  • FtP found proved that the prescribing was potentially hazardous.
  • FtP found proved that the prescribing was not in the best interests of Jean Stevens.

20 May 1999: Dr Barton prescribed diamorphine with a dose range of 20–200 mg daily subcutaneously

  • FtP found proved that there was insufficient clinical justification for such prescriptions.
  • Dr Barton admitted that the dose range was too wide.
  • Dr Barton admitted that the prescribing created a situation where drugs could be administered which were excessive to the patient’s needs.
  • FtP found proved that the prescribing was inappropriate.
  • Dr Barton admitted the prescribing was potentially hazardous.
  • FtP found proved the prescribing was not in the best interests of Jean Stevens.

20 May 1999: Dr Barton prescribed midazolam with a dose range of 20–80 mg subcutaneously

  • FtP found proved that there was insufficient clinical justification for such prescriptions.
  • Dr Barton admitted that the dose range was too wide.
  • Dr Barton admitted the prescribing created a situation where drugs could be administered which were excessive to the patient’s needs.
  • FtP found proved that the prescribing was inappropriate.
  • FtP found proved that the prescribing was potentially hazardous.
  • FtP found proved that the prescribing was not in the best interests of Jean Stevens.

21 May 1999: a further prescription was written by Dr Barton for 10 mg oramorphine in 5 ml, 4 times a day, 20 mg at night

21 and 22 May 1999: doses of oramorphine, diamorphine and midazolam were subsequently administered to the patient

  • FtP found proved that there was insufficient clinical justification for such prescriptions.
  • Dr Barton admitted that it created a situation where drugs could be administered which were excessive to the patient’s needs.
  • FtP found proved that the prescribing was inappropriate.
  • FtP found proved that the prescribing was potentially hazardous.
  • FtP found proved that the prescribing was not in the best interests of Jean Stevens.

In relation to advice:

  • Dr Barton admitted that she did not obtain the advice of a colleague when Jean Stevens’ condition deteriorated.