Appendix 2: Detailed patient case studies
Case Study – Arthur Cunningham
Panel comments – 6
- The Panel has not seen any document in the clinical records to confirm the rationale for the two-fold increase in the dose of diamorphine and hyoscine and the one-third increase of midazolam.
In her police interview, Dr Barton stated:
“[The nurse] recorded a report from the night staff that Mr CUNNINGHAM was in pain when being attended to, and was also in pain with the day staff, though it was suggested that this was especially in his knees. In any event, the syringe driver was increased to 40 mgs of Diamorphine, and the Midazolam to 80 mgs, together with 800 mcgs [micrograms] of Hyoscine.”
During the FtP hearing, Dr Barton said that nurses had informed her that Mr Cunningham was becoming tolerant of the diamorphine and she needed “to increase the dose a little bit to give him the same level of comfort”.
Panel comments – 7
- Dr Barton did not record the explanations for the increase in dosage she provided to the police or to the FtP hearing in Mr Cunningham’s clinical notes at the time of her assessment.
On 25 September, Dr Sarah Brook, a GP in Dr Barton’s practice who assisted at the hospital, recorded in the clinical notes: “remains very poorly on syringe driver, for TLC”.
Dr Barton wrote another prescription increasing the ranges for diamorphine to 40–200 mg, midazolam 20–200 mg and hyoscine 800 micrograms–2 gm.
The drug chart records that, at 10:15, diamorphine 60 mg, midazolam 80 mg and hyoscine 1,200 micrograms were administered by syringe driver over 24 hours.
Panel comments – 8
- The Panel notes that there was an error in the prescribed dose of hyoscine, which was written as mg rather than mcg (micrograms).
- The Panel has not seen any document in the clinical records to confirm the rationale for the increase in the prescribed dose range.
In her police interview, Dr Barton stated:
“I anticipate that in the usual way I would have seen Mr CUNNINGHAM again that morning, 25th September. I wrote a further prescription for the Diamorphine, Hyoscine and Midazolam, this time with the ranges being 40 - 200 mgs, 800 mcgs - 2 grams, and 20 - 200 mgs respectively. It appears then that the Diamorphine was increased to 60 mgs, with 90 mgs of Midazolam and 1200 mcgs of Hyoscine at 10.15 that morning. My expectation is that this increase was necessary to relieve Mr CUNNINGHAM’S pain and distress. It is likely that by this time Mr CUNNINGHAM would have been becoming tolerant to opiates, and that might have added to the need to increase the doses of medication.”
During the FtP hearing, Dr Barton stated that she did not see Mr Cunningham on this day.