Chapter 3: The experience of patients and families on the wards
How the drugs were given
Chapter 2 has explained that opioids were prescribed with a wide range of dosage in a practice described as ‘anticipatory prescribing’. Reinforcing the analysis from the data are eyewitness accounts of how the drugs were administered by nurses in accordance with this practice.
Pauline Spilka worked as a nursing auxiliary at the hospital from 1995 until 1999. At the time she made her statement in 2001, she had eight years’ experience of caring for elderly patients within both the public and private sectors. Prior to working in the hospital, she was employed at the Acacia House Nursing Home in Horndean, Hampshire, as a night shift nursing auxiliary caring for elderly residents, and at the Greylingwell Hospital in Chichester, West Sussex, where she worked as a nursing auxiliary on an elderly mental health ward.
In April 2001, Pauline Spilka provided Hampshire Constabulary with a statement which included the following description of how patients were given the drugs:
“Patients would arrive on the ward to be admitted by the clinical assistant or if she was not available then occasionally Dr LORD. If the patient was accompanied by relatives then a discussion would be held and a care plan would be drawn up; The care plan would involve other specialists such as the Physiotherapists, Occupational Health, Dieticians etc. Each patients care plan was included with their general notes and another of my functions would be to ensure that I knew what the care plan was in respect of each patient.
It was some while later that I was to learn that all patients upon their admission were written up (by the doctor) who authorised the use of a syringe driver if appropriate. This enabled any member of the nursing staff to set up a syringe driver for a patient without any further reference to the doctor. Although I cannot be certain I think this was explained to me by the Staff Nurse ... I am sure however that this was not common knowledge among the majority of the nursing auxiliaries.
Despite my experience in elderly care I had never heard of a syringe driver prior to working at the War Memorial Hospital. I was later to learn that it was a device used for pain relief in seriously ill patients, the driver delivers a constant dosage over a period of time. It was also clear to me that any patient put onto a syringe driver would die shortly after. During the whole time I worked there I do not recall a single instance of a patient not dying having been put onto a driver.
I have never received any training in respect of a syringe driver nor have I ever used one in order to administer drugs to any patient.
The regime on the ward was as follows. If one of the trained members of nursing staff considered that a patient required the use of a syringe driver then they would seek the approval of another trained nurse. Having reached agreement then the driver would be set up. The needle would be inserted into the patients back so as to make it impossible for it to be removed.
I have witnessed disagreements between nurses where one of them did not agree that a patient required the use of a syringe driver. These disagreements would be resolved by the nurse requiring the syringe driver approaching a more senior nurse and obtaining their consent. Once that consent had been obtained then the syringe driver would be set up.
I have never known of a case where a staff member did not obtain permission to use a syringe driver from senior staff.
I referred earlier to a particular case that troubled me deeply. The patients name was ... He was aged about 80 and during 1997 or 1998 was a patient on the ward suffering from stomach cancer.
[The patient] was quite a character who loved to eat sweets and crisps that had been brought in for him by friends and family. He would eat so many that the staff would sometimes have to confiscate them from him to stop him from being sick. Mentally he was alert and capable of long conversations I recall that he was in room 8B which is a ward for 4 patients all of whom spent many hours chatting together and watching TV. If I am right, at the same time another of the other patients had been a professional footballer with Portsmouth and the patients would chat for hours about old matches.
Physically he was able to walk with the aid of a zimmer frame and was able to wash himself. It is important that patients are encouraged to continue with these tasks allowing themselves a level of independence and more importantly dignity. [The patient] however tended to be rather lazy in this respect and in many ways was quite a difficult patient. He liked to think of himself as being more ill than the other patients and seemed to quite enjoy the attention this brought. However he would sometimes get quite tearful about his condition.
I remember having a conversation with one of the other auxiliaries, Marion BERRY, we agreed that if he wasn’t careful he would ‘talk himself onto a syringe driver’. [The patient] although frail was not (in my opinion) near death at that time.
One day I left work after my shift and he was his normal self. Upon returning to work the following day I was shocked to find him on a syringe driver and unconscious ...
I said ‘Did you tell him he’d be dead at the end of this?’
[The nurse] said ‘You know he’s gone downhill we don’t know how long he’s got left’
I said ‘That’s not the issue did you tell him he’d be dead?’
[The nurse] was unable to answer me.
The previous evening [the patient] had been alert and perfectly capable of decision making and conversation I was concerned that the inevitable outcome if he succumbed to a syringe driver would be his death. I wanted to be reassured that he had been given a full explanation before allowing a syringe driver to be introduced. [The nurse] was unable to provide me with any reassurance. Knowing [the patient] as I did I am confident that he to would not have allowed the introduction of a syringe driver had he known of the outcome.
[The patient] subsequently remained unconscious until his death. He lasted some while. Whilst accepting that I have no medical qualification I am concerned that he was certainly not in imminent fear of death when he allowed the syringe driver to be introduced.
I know that there was considerable disquiet amongst both the nursing and auxiliary staff over [the patient].
After the syringe driver had been introduced I felt unable to discuss [the patient] with his family when they visited. Families often naturally seek reassurance from any member of staff when they visit. Things like ‘How does he look to you?’ I was so upset by the whole situation that I felt unable to face them until his death. I was worried that I would say something out of turn.
There was an atmosphere between [the nurse] and I which led to us speaking in his office on a couple of occasions over the following week. He accused me of ‘Failing to come to terms with death’. This was ludicrous by then I had over 7 years experience in elderly care and had seen many many deaths. He failed to see my point that this death had been unnecessary.
I cannot explain why I didn’t speak out against the regime within the ward. I feel incredibly guilty about the death of ...
I can recall a patient being admitted onto the ward almost unconscious. She was an elderly Welsh lady. [A nurse] spoke to the family and explained that the lady was in pain and that all in all the syringe driver should be used to relieve her pain. The family were united in the belief that all medication should be stopped to see if that brought about a change in their mothers condition.
The medication was withdrawn and over the next couple of days the lady improved beyond all recognition within a short time I remember walking arm in arm with her along the corridor having a conversation. She was subsequently discharged home to live with her daughter. I understand that she lived for a further year. This would certainly not have happened were the syringe driver set up upon her arrival.” (HCO110756, pp1–3)
The Panel found nothing in any of the records, medical or otherwise, it has examined that would undermine Pauline Spilka’s account. Her experience is confirmed by the case studies the Panel has prepared – these are intended to convey the experience of the patients as recorded in their medical records (without actually publishing those records). The Panel has considered issues concerned with the particular syringe drivers, known by their tradename of Graseby, and is aware of the Hazard Notices which applied. The Panel's analysis does not rest upon any issue relating to these notices.
Case Study 1 illustrates a pattern of prescribing and administering which quickly led to death. The patient, however, was being considered for placement back in a nursing home only days before her death.