Appendix 2: Detailed patient case studies
Case Study – Arthur Cunningham
Panel comments – 1
- The Panel has not seen any document in the clinical records to confirm Dr Barton’s rationale for prescribing diamorphine and midazolam at this stage.
- The Panel notes that Mr Cunningham was opioid naïve.
- The Panel notes the wide dose range of diamorphine which was prescribed in a patient who had renal impairment.
In relation to the prescription for diamorphine and midazolam, Dr Barton stated in an interview with Hampshire Constabulary in April 2005:
“I was concerned that although the [morphine oral solution] would assist in providing pain relief, this might become inadequate. The sacral sore was very significant, being the size of a fist, and the second largest I have ever seen. It was clearly causing [Mr Cunningham] significant pain and distress at the time when I assessed him. Accordingly, I decided to write up diamorphine on a proactive basis and a dose range of 20 to 200 mgs. This was a wide range, but I was conscious that inevitably the medication would be commenced at the bottom end of this range, if given at all. Any increase would then ordinarily be with reference to me or another practitioner. In addition to the diamorphine I prescribed 200 - 800 mcgs of Hyoscine and 20 - 80 mgs Midazolam. These medications were prescribed by me purely with the aim of alleviating [Mr Cunningham’s] significant pain, distress and agitation … I have no specific recollection, but I anticipate that the second dose of [morphine oral solution] had been insufficient in relieving the pain and anxiety, and in the circumstances, to ensure that [Mr Cunningham] was free from pain and anxiety, and had a settled and an uninterrupted night, the Diamorphine was then commenced, providing continuous pain relief for what was clearly a most unpleasant ulcerated wound … I cannot now say if I was specifically contacted about the institution of the diamorphine. Ordinarily I would have been contacted, but the administration was at the lowest end of the dose range, and its provision had been agreed with me and the nursing staff earlier, so it is possible that specific reference was not made.”
In 2009, Dr Barton told the General Medical Council (GMC) Fitness to Practise (FtP) hearing:
“… first of all, I was aware of how very ill he was and that he would possibly very shortly be on an end-of-life pathway rather than purely palliative care. I was also aware when I saw him at the Day Hospital with Dr Lord that there had been problems with his tablets, difficulty swallowing them, and that if we were going to give adequate analgesia we might well need to give this subcutaneously rather than as tablets or orally. I know he had taken milk overnight but his eating and drinking, and his taking of tablets, was possibly a bit suspect … In my opinion, he was then on a palliative care pathway. We had to keep him comfortable. That depth and size of sore must have been very uncomfortable and very distressing for him, particularly when it was dressed and seen to … My priorities were that I was aware that he was very ill, very frail and I was going to keep him comfortable … There was a remote possibility that with adequate protein drinks, with proper local treatment to the sore, it might improve, but I had never in my clinical career seen one survive. My course of treatment was exactly as it would have been, even if I thought we could heal the sore. I was minded to keep him comfortable, reduce any anxiety and distress he may have had. I was not considering him at that point in that afternoon as being terminal. I was, however, aware that he had just finished a course of antibiotics issued by the Day Hospital and that despite that the sore was very much worse, so I was not very optimistic about his prognosis but I was not going to do anything to hasten his death or to his detriment.”
Dr Barton also told the FtP hearing:
“In my opinion there were two main reasons for starting the syringe driver. My advice to my day staff, when I saw Mr Cunningham that afternoon, would have been, Start with the [morphine oral solution], but you do have a pro-active prescription for the syringe driver should his distress and pain deteriorate and you feel you are going to be able to manage it with oral medication. Both the diamorphine and the midazolam would have been ideal medication to control his discomfort, distress, anxiety overnight, as well as the pain he was receiving … So that was what the pro-active prescription was for.”
Panel comments – 2
- Dr Barton did not record the explanations she provided to the police or to the FtP hearing in Mr Cunningham’s clinical notes at the time of her assessment.
On 22 September 1998, the nursing notes record:
“[Son] has telephoned. Explained that syringe driver containing diamorphine, midazolam was commenced yesterday evening for pain relief and to allay his anxiety following an episode when Mr Cunningham tried to wipe sputum on a nurse saying he had HIV and was going to give it to her. He also tried to remove his catheter and empty the bag and removed his sacral dressing throwing it across the room. Finally he took off his covers and exposed himself.”
At 20:20, 20 mg of diamorphine and 20 mg of midazolam were administered subcutaneously as a 24-hour infusion. The nursing notes record: “Driver running as per chart. Very settled night.”
On 23 September, the nursing notes record that Mr Cunningham was seen by Dr Barton and that “he has become chesty overnight to have hyoscine added to driver … son informed of deterioration … asked if this was due to the commencement of the syringe driver … informed that [Mr Cunningham] was on small dosage which he needed.”
The syringe driver set up the evening before was paused and hyoscine added; there is no record on the drug chart that any remaining drug was discarded. At 09:25, the syringe driver was restarted with diamorphine 20 mg, midazolam 20 mg and hyoscine 400 micrograms to be administered over 24 hours.
At 13:00, the clinical records note that Mr Cunningham’s son was:
“… very angry that syringe driver has been commenced. It was explained yet again that the contents of the syringe driver were to control his pain. It was also explained that the consultant would need to give her permission to discontinue the driver and we would need alternative method of giving pain relief … now fully aware that [Mr Cunningham] is dying and needs to be made comfortable.”
The drug chart further records “discarded” on the 09:25 diamorphine dose and, at 20:00, the administration of 20 mg of diamorphine, 60 mg of midazolam and 400 micrograms of hyoscine was commenced.