Chapter 6: The General Medical Council

The Fitness to Practise Panel retired to decide the case in private. Its determination was set out in three parts. Part One dealt with the general issues that had required consideration during the course of the case (GMC100948, pp209–21). These were as follows:

1. Inappropriate transfers onto Dryad and Daedalus wards

• The panel heard and accepted evidence that due to “pressure on bed space”, patients would be transferred to Dryad and Daedalus wards when their needs were “beyond the staffing and equipment capabilities” of those wards. (GMC100948, p209)
  
• Dr Reid was among the witnesses who were asked in cross-examination about the tendency of hospitals when sending patients for “sometimes presenting a slightly rosier picture of the patient’s general medical stability”. (GMC100605, p232)  
  
• Dr Reid explained that this could cause “Sometimes a very significant problem” through “Patients or relatives being told that they were coming to the War Memorial Hospital for rehabilitation when the reality would be that on assessment the chances of rehabilitation were remote”. (GMC100605, p233)
  

2. Propensity to sudden deterioration, the effects of transfer and the appropriateness of investigation

• The Fitness to Practise Panel heard and accepted evidence that many of the patients on Dryad and Daedalus wards “had a natural propensity toward sudden deterioration and even death, no matter how well cared for”.
  
• It accepted evidence that when patients were subject to transfers it was frequently followed by deterioration in the patient.
  
• The panel said that, in addition to early assessment being necessary, it was of the view that further investigations or assessments may have been needed.
  
• However, the panel also noted that “there appeared to be agreement among the experts that when a patient was on the terminal pathway, it would be inappropriate to subject the patient to unnecessary investigation”. (GMC100948, p209)
  

3. Dr Barton’s dealings with patients’ relatives

• Evidence was given by doctors, nurses, consultants and patients’ relatives about Dr Barton’s interactions with patients’ relatives.
  
• The panel noted that “most [witnesses] characterised your approach to relatives as caring and compassionate”.
  
• However, it also noted that some relatives described Dr Barton as “brusque, unfriendly and indifferent”.
  
• The panel did not have to make any findings in relation to this as it did not form any part of the charges, but it did conclude: “your straightforward approach was not appreciated by all relatives” and “to some you might at times appear distant or even unfeeling, albeit that this was far from your intention”. (GMC100948, p210)
  

4. 'Happy for nurses to confirm death'

• The panel accepted Professor Ford’s evidence that it was appropriate for staff to delegate the task of confirmation of death to nurses in circumstances where there was “a natural potential to deteriorate rapidly and without warning”.
  
• The panel also noted that it would have been preferable for there to have been a policy for the ward, rather than a necessity for Dr Barton to include this on individual patients’ notes. (GMC100948, p210)
  

5. The role of note taking in clinical care

• The poor note taking by Dr Barton played a large role during the evidence and was the subject of much criticism. (GMC100948, p210) 
  

6. The absence of notes of specific events

• The Fitness to Practise Panel referred to medical students being frequently taught “if it isn’t recorded it didn’t happen”  but concluded that: “as Mr Langdale pointed out in his closing remarks, you are of undisputed good character and that adage cannot be applied to the Panel’s consideration of the facts.”
  
• The panel took the view that the lack of a note was unhelpful but did not automatically mean an event or assessment Dr Barton said had happened had not occurred. (GMC100948, p211)
  

7. Allegations that Dr Barton did not sufficiently record the drug regime in respect of specific patients

• The panel said when considering risk, doctors had to consider not only what might happen when the most highly trained and experienced nurses were on duty, but also when the least trained and experienced were on duty. It said: “patients were entitled to expect that clear written instructions would be available to all those who might be expected to administer the prescription.”
  
• The panel went on to say it did not accept that it was “safe or prudent” for Dr Barton to simply tell nurses what she expected the drug regime to be, leaving them to pass it on to each other in verbal handover sessions at shift changes. (GMC100948, pp211–12)
  

8. Euphemisms relating to end of life status

• The panel accepted evidence from a number of witnesses that it was usual in the health service to use ‘TLC’ (tender loving care) or ‘make comfortable’ as euphemisms for patients who were to be treated palliatively. (GMC100948, p212)
  

9. Guidelines and the analgesic ‘ladder’

• The panel accepted the evidence that the BNF was “the definitive evidence based guide for doctors on the prescribing of drugs”.
  
• Dr Barton gave evidence that she kept a copy of the Palliative Care Handbook (the Wessex Protocol) in her pocket when on the wards.
  
• Both experts agreed the World Health Organization’s analgesic ‘ladder’ emphasises the importance of increasing from weaker to stronger analgesics in steps. The panel said: “Professor Ford encapsulated this principle as ‘start low, go slow’.” (GMC100948, p212)
  

10. Opiates in the treatment of distress, restlessness, agitation and pain

• There was a range of opinion given in evidence as to the appropriateness of using opiates in the control of distress, restlessness and/or agitation in the presence or absence of pain.
  
• Dr Barton and Professor Sikora, among others, gave their opinion that their euphoric and other properties were helpful.
  
• Professor Ford did not share this view and “noted that such a course is neither promoted nor recommended in the palliative literature and guidelines”. (GMC100948, p213)
  

11. Side effects/adverse consequences of opiates

• The panel heard evidence about common side effects of the use of opiates.
  
• Professor Ford told the panel that, because of these side effects, “when dealing with elderly patients, it was incumbent on prescribers to exercise extreme caution in determining dosage”. (GMC100948, p213)
  

12. The diamorphine/midazolam mix

• Dr Barton and Professor Sikora agreed that midazolam had a powerful sedating effect, and caution was needed when used with diamorphine.
  
• The panel noted that Professor Sikora had said that when treating a patient on the terminal pathway, the analgesic ‘ladder’ and guidelines were still necessary to avoid over-sedating “because the danger otherwise is that one can end up with a patient who is unnecessarily unconscious or dead”. (GMC100948, p214)
  

13. Prescribing opiates outside the guidelines

• The panel accepted the evidence it heard from both medical experts and a number of consultants that, on occasion, it is necessary to prescribe outside the guidelines.
  
• Dr Barton’s Counsel had put forward the argument that where there was no note of why she had prescribed outside the guidelines, the panel had no information on which to base a view that she had acted inappropriately and therefore those charges could not be proved. The panel members did not accept this argument and said that in those cases they had “to review all the evidence and then ask themselves whether they could be sure on the basis of that evidence that [Dr Barton] had prescribed inappropriately”. (GMC100948, p215)
  

14. Anticipatory prescribing and the delegation of powers

• The panel accepted that anticipatory prescribing was not an uncommon practice; it was designed to ensure that nursing staff had the discretion to prescribe medication without the necessity to wait for a doctor to respond to a call.
  
• The panel said that this prescribing carries risks, particularly where the prescription was for a syringe driver with a mixture of diamorphine and midazolam.
  
• It was Dr Barton’s case that these risks were adequately protected by the fact that “the drugs could only be administered by two fully qualified nurses working together; and that the nurses on Dryad and Daedalus were of a caliber that rendered the risk acceptable” (GMC100948, p215). The panel said that Dr Barton made an “apparent assumption” that the required dose would increase. This meant that the lowest dose in Dr Barton’s anticipatory ranges was set at a higher level than the patient’s current prescription.
  
• The panel said this carried a risk for nurses, if they could not get hold of a doctor in the circumstances envisaged by Dr Barton. If a nurse thought the lowest dose in the range was too high for their patient’s needs, the only options were not to give the prescription at all, or to give it at too high a dose.
  
• The panel accepted Professor Ford’s view that “in anticipatory prescribing a dose range which allowed for an increase of more than 100% from the lowest to the highest parameter was too wide”. (GMC100948, p216)
  
• The panel said that while Dr Barton’s practice of “doubling up” a dose which was not controlling pain would “prevent the manifestation of breakthrough pain … it also greatly increased the risk of over-sedation and adverse side effects”. (GMC100948, p216)
  
• In the panel’s view, this practice demonstrated Dr Barton’s approach to protecting patients from pain even at the cost of protecting them from over-sedation and adverse side effects.
  
• It was agreed that the doses actually administered never reached the highest doses in the ranges prescribed. The panel commented that this was fortunate. However, it went on to say: “the fact remains that this method of prescribing gave rise to the risk that the highest doses could be administered. This is a matter which the Panel is obliged to take into account when considering the appropriateness of the prescribing and whether or not it was in the best interests of the patient.” (GMC100948, p216)
  

15. Syringe drivers

• A great deal of evidence was given in relation to syringe drivers. The panel concluded that there was value in their use.
  
• It noted that on Dryad and Daedalus wards, syringe drivers tended to be loaded with combinations of diamorphine and midazolam, frequently at doses of 20 mg of each, routinely doubling every 24 hours.
  
• On those wards, there were no facilities for intravenous hydration and thus patients who were unable to swallow, through unconsciousness or otherwise, would not receive hydration, which ultimately leads to death.
  
• The panel said: “it was in this context that medical and nursing staff on these wards recognised that starting a patient on a syringe driver was an acknowledgement of the fact that the patient was now on a terminal pathway and not expected to live beyond a matter of days.” (GMC100948, p217)
  

16. Syringe drivers and the immediate relief of pain

• In its determination, the panel noted that Dr Barton had expressed surprise that Professor Ford had explained there could be a delay of up to 20 hours before analgesia administered through a syringe driver reached its optimum level. Dr Barton had said it was her experience that it took effect more quickly. When asked about the potential for dealing with immediate pain by single injection rather than placing the patient directly on a syringe driver, Dr Barton told Mr Kark: “I was not in the habit of using intramuscular or subcutaneous Diamorphine in that way.” Mr Kark replied: “Instead of which what you effectively did was handed the nurses the power to start the path for this lady’s death.” Dr Barton responded: “I did.” (GMC100948, p217)
  

17. Titration and the use of syringe drivers

• When treating a patient who had not previously been prescribed opiates (an opioid-naïve patient), Professor Ford said the first issue was to establish the level of analgesia needed to ensure that the patient was pain free but also remained alert and free of adverse side effects.
  
• The panel noted: “in Professor Ford’s view … this could most effectively be achieved by means of titration, ie, treating the patient with a series of escalating doses and observing the effect until a daily dose which completely controlled the pain was found.” (GMC100948, p218)
  
• When moving a patient who was already receiving opiates on to a syringe driver, nursing staff had the necessary conversion charts to calculate what the equivalent dose was and how to move to the syringe driver without increasing or decreasing cover during the transition.
  
• The panel noted the following exchange: “When asked by Mr Kark about the need for titration prior to commencing a syringe driver, Professor Sikora said ‘That would be the ideal situation to go for; to have either oral morphine or long-acting morphine, or in four-hour injections, work out over a two or three day period what the dose is, set that and then give the subcutaneous morphine.’ He stated that unless you did that, there was a serious danger that you are either going to start too low or too high.” (GMC100948, p218)
  
• The panel went on to say: “By contrast, you evinced a marked reluctance to titrate doses before commencing patients on syringe drivers. You told the Panel ‘we simply did not have the level of staffing to do that on a ward of 24 people’.” (GMC100948, p218)
  
• The panel also noted that Dr Barton confirmed that, throughout the three years covering the 12 cases, titration was not carried out. The panel said she gave evidence saying: “I was not taught it, I was not familiar with using it … it was not practical … it just was not feasible.” (GMC100948, p219)
  

18. The effect of staffing pressures on the prescribing practice

• The panel said that it had: “received evidence from a wide range of witnesses that the impression given to the visitor to Dryad and Daedalus wards was that the wards were well run and that patients were taken good care of. You were full of praise for your nursing staff and the job they did. You were clear that the quality of nursing care that your patients received was not compromised by staffing pressures: you stated that opiates were never started earlier, or at a higher rate, because of inadequate staffing; you told the Panel that that would have been quite inappropriate. Your view on the effect of staffing pressures was borne out by Sister Joins and a large number of other witnesses.” (GMC100948, p219)
  
• However, the panel noted that Dr Barton also said her “system of anticipatorily prescribing wide ranges of opiates for delivery by syringe driver with what some might view as a high starting dose, and in the absence of titration, was a direct and necessary result of staffing pressures.” (GMC100948, p219)
  
• The panel highlighted that the defence expert, Professor Sikora, had agreed this might be a reasonable proposition for an individual patient in distress and pain. That was because the staff would not have time to observe patients and increase medication in the optimal fashion. 
  
• However, the panel also said the opposite might be true, as this strategy “might conversely create the need for a higher level of observation if patients are to be adequately protected in the event that adverse consequences [from the higher doses of drugs] manifest themselves.” (GMC100948, p219)
  

19. The role of consultants

• Much evidence was heard about the role of consultants. All three consultants gave evidence during the hearing. Dr Reid and Dr Jane Tandy gave evidence for the GMC. Dr Lord was called by Dr Barton. 
  
• The panel said it had heard “at the time in question, the presence of Consultants on Dryad and Daedalus wards was extremely limited. Although the Consultants who gave evidence before the Panel were supportive of you, their evidence tended to suggest that they had not critically examined your prescribing practice, and in many instances had not appreciated your admitted prescribing failures. Had they done so, this should have resulted in appropriate changes being made to your prescribing practice.” (GMC100948, p219)
  

20. Mr Langdale’s argument that the very fact that senior medical staff and the visiting pharmacist did not object indicated that Dr Barton was doing nothing wrong 

• The panel said: “As stated above, the Panel took the view that the Consultants on the ward systematically failed to critically examine your prescribing practice. While the effect of this failure might have been to reinforce your view that you were not acting inappropriately, it in no way rendered your inappropriate conduct appropriate. The Panel noted that as a medical practitioner you retained ultimate responsibility for your own actions.”  (GMC100948, p220)
  
• The panel also said: “In respect of the pharmacist, the Panel has not had the advantage of receiving any evidence from her. In the circumstances, the Panel is unable to draw any conclusions with respect to your actions or inactions as a consequence of her actions or inactions. However, the Panel noted your admissions with regard to your own prescribing deficiencies, and that it has heard no evidence that these were detected and acted upon by the pharmacist.” (GMC100948, p220)
  

21. The principle of ‘double effect’

• The panel heard evidence from Professor Ford about the ‘double effect’ of drugs given to seriously ill patients to palliate symptoms (that is, to relieve symptoms without treating the cause). The panel highlighted that Professor Ford had said that these types of drugs “may lead to a shortening of life through adverse effects. That is well accepted as being a reasonable and appropriate aspect that may happen when one adequately palliates symptoms.” (GMC100948, p220)
  
• Professor Ford said that the issue of prescribing these drugs is to ensure the dose is high enough to have the necessary effect, but not to go beyond that. As an example, he said particular care needed to be given with drugs that sedate because they relieve distress but, at the same time, can produce respiratory depression and hasten death.
  
• The panel said that Dr Barton was “clearly aware of the principle of double effect” and when asked about the risk of her prescribing causing “respiratory depression or lowering [a patient’s] conscious level”, the panel highlighted that Dr Barton said: “I accepted that that was a price that we might have to pay in exchange for giving him adequate pain and symptom relief.” (GMC100948, p221)
  
• Throughout her evidence, Dr Barton said that her primary concern with such patients was that she did not wish them to be more alert to feel more pain. She was prepared to accept the risks associated with the drugs in order to provide adequate analgesia and sedation.
  
• The panel said her answers “gave a clear insight into how you viewed the desirability of balancing pain relief with the desirability of keeping the patient as free as practicable from the side effects of opiates”. (GMC100948, p221)