Chapter 3: The experience of patients and families on the wards
Case Study 1 – Ethel Thurston summary
In 1999, Ethel Thurston was aged 78 and lived in a nursing home. She had learning difficulties and was thought to have the mental capacity of a ten year old. Miss Thurston had once held down a job in a bank, was able to perform simple tasks and had been able to travel across London independently. She was long-sighted and wore glasses. Miss Thurston was said to have become aggressive from January 1999, and by June the nursing home was considering seeking a referral to a psychiatrist specialising in old age.
On 15 June, Miss Thurston fell and fractured her left neck of femur. She was admitted to the Royal Hospital Haslar (‘Haslar Hospital’). She had a left cemented hemiarthroplasty (partial hip replacement). On 29 June, Miss Thurston was transferred to Gosport War Memorial Hospital (‘the hospital’) for rehabilitation and mobilisation where she remained until she died on 26 July.
Miss Thurston was assessed at Haslar Hospital by Dr Richard Ian Reid on 24 June 1999. He noted that she was “pleasant and cooperative … able to move both legs without pain and … to attempt to stand … she did not appear to be in any pain … she had the physical potential to remobilise”. On 29 June, Miss Thurston was admitted to Gosport War Memorial Hospital for rehabilitation, care and mobilisation.
At the time of her admission to the hospital, Miss Thurston was able to wash, dress and feed herself with encouragement and some help. Although she had a limited vocabulary, she had no difficulty in communicating. In addition to her fractured femur, Miss Thurston had an ulcer on her lower left leg, was prone to constipation and had in recent years become incontinent, which had necessitated the use of a catheter at Haslar Hospital. Miss Thurston’s drug therapy was oxybutynin (for urinary incontinence) and zopiclone (a night sedative).
On admission to the hospital, the nursing notes record Miss Thurston as demented with learning difficulties; in need of hoisting with “no inclination to rehabilitate”; very reluctant to take food and fluids; and “willing to feed herself only if she feels like it”. In addition, “her behaviour can be aggressive and she has been known to strike staff”.
On 1 and 7 July, a fentanyl patch (25 micrograms) was prescribed by Dr Jane Barton, to be given every three days. A patch was administered on 1 July and then every three days. The last patch was applied on 25 July.
On 7 July, a five-day course of oral antibiotics was prescribed and administered.
On 8 July, Dr Victoria Banks, a psychiatrist specialising in old age, observed that Miss Thurston seemed to have dementia; however, she was less certain about whether she had depression. Dr Banks recommended that Miss Thurston’s urinary catheter be removed and that she be treated with subcutaneous fluids and intravenous antibiotics. The nursing notes record that Dr Barton decided against intravenous antibiotics at that time.
On 16 July, Miss Thurston was noted to be “much more settled”. The plan at that stage was to transfer her back to the nursing home and, on 19 July, she was seen by Dr Reid who agreed with the plan for placement back in the nursing home. He noted that she had pain in her knees, was refusing oral analgesia and was “better on fentanyl”.
On 25 July, the care plan entries record that Miss Thurston was a “little brighter”. The clinical notes confirm that Dr Beasley saw Miss Thurston later that day and noted: “Refusing all fluids and food … turned face to the wall … problems with constipation, refuses painkiller-fentanyl patches only can be used.” The nursing notes record that Miss Thurston’s “general condition seems to be deteriorating”.
On 26 July, Dr Barton saw Miss Thurston. She made a brief note in the clinical records – “further deterioration overall … please keep comfortable. I am happy for nursing staff to confirm death” – and prescribed diamorphine 20–200 mg and midazolam 20–200 mg to be administered by 24-hour subcutaneous infusion as required. The following record was made in the nursing notes: “Syringe driver started diamorphine 90mg. Midazolam 20mg.” The drug chart records that these doses were administered at 11:15. At 19:00, a nurse confirmed Miss Thurston’s death.
Miss Thurston’s death certificate recorded the cause of death as bronchopneumonia and senile dementia.
1 and 7 July 1999
- At the time of her transfer to the hospital, Miss Thurston was not in pain or receiving any analgesia.
- The Panel has not found any entries in the clinical notes for 1 and 7 July. The care plan entries for these dates are scanty.
- The Panel has not found any document in the clinical records to show that fentanyl was clinically indicated at any time.
- The Panel has not found any document in the clinical records to confirm Dr Barton’s rationale for prescribing fentanyl on 1 and 7 July.
- The Panel has not seen any document to confirm that nurses consulted the British National Formulary (BNF) guidance or the Wessex guidelines1 to scrutinise the fentanyl prescription, or that they refused to administer the fentanyl patch at any time.
- It is not clear from the records why antibiotics were prescribed. The records indicate that this was related to the catheter and/or the urinary tract.
- The records indicate that Miss Thurston’s catheter was not removed until 11 July, when it became blocked.
8 July 1999
- The Panel has not found any document to confirm the reason for Dr Barton’s decision that intravenous antibiotics should not be commenced.
- The Panel notes that there was no facility at the hospital for administering drugs and fluids intravenously.
- The Panel has not found any record to confirm that Miss Thurston was treated with subcutaneous fluids.
19 to 24 July 1999
- The Panel has not seen any document in the medical records to confirm the cause or degree of pain in Miss Thurston’s knees on 19 July.
- There are no entries in the clinical notes from 19 July until 25 July. The care plan entries for this period are scanty. The nature of Miss Thurston’s condition during this period is not clear.
25 and 26 July 1999
- The Panel has not seen any document in the clinical records to confirm the nature and extent of Miss Thurston’s deterioration on 26 July.
- It is not clear from the medical records why, on 26 July, Dr Barton requested nursing staff to keep Miss Thurston comfortable and why Dr Barton noted that she was “happy for nursing staff to confirm death” when Dr Reid had decided that Miss Thurston “had the physical potential to remobilise”. In addition, on 16 and 19 July, the plan was that she should return to a nursing home.
- The Panel has not seen any document in the clinical notes to confirm that nurses engaged in any adequate end of life care discussion with Miss Thurston’s family.
- The Panel notes the prescribing of diamorphine and midazolam in high and very wide dose ranges on 26 July.
- The Panel has not found any document in the clinical records to show that diamorphine and midazolam were clinically indicated on 26 July.
- The Panel has not found any document in the clinical records to show that the fentanyl patch was removed at any point prior to the commencement of diamorphine. The Panel notes that if the fentanyl patch had been removed when diamorphine was commenced, a substantial amount of fentanyl would remain in the body and be clinically active for several days.
- The 90 milligram (mg) starting dose of diamorphine was excessive, at least three times the recommended dose equivalent when changing from a fentanyl patch to subcutaneous diamorphine.
- The Panel has not seen any document to show that nurses consulted the BNF guidance or the Wessex guidelines to scrutinise the doses of diamorphine and midazolam, questioned any of the consultants, doctors or the pharmacist at the hospital in respect of the prescription and doses, or refused to administer the diamorphine and midazolam.
- The Panel has not seen any document in the medical records to show the rationale for the decision to commence the diamorphine infusion at a dose of 90 mg over 24 hours on 26 July.
- The Panel has not seen any document in the medical records to show that nurses consulted the BNF guidance, the Wessex guidelines, any doctor or the pharmacist when commencing the administration of diamorphine at 90 mg.
- The Panel has not seen any document to show that nurses were provided with any written guidance from the doctors, consultants or Portsmouth HealthCare NHS Trust on when to commence the administration of diamorphine and midazolam or the choice of starting dose.
- Overall, the Panel found a lack of information in Miss Thurston’s clinical notes. Entries were made on only 8 of the 28 days that Miss Thurston was in the hospital.
- The Panel found a lack of information in Miss Thurston’s daily nursing notes and care plans. The nursing notes and care plans seen by the Panel were scanty, were not personalised to the patient’s needs and contained missing entries for entire days. There was nothing in the care plans that took account of Miss Thurston’s cognitive impairment, capabilities, likes, dislikes and preferences.
- The Panel found no pain charts or pain management plans in Miss Thurston’s medical records. It is not clear to the Panel how Miss Thurston’s pain and the effectiveness of any analgesia were adequately monitored.
- The Panel has not seen any nutrition or fluid charts among Miss Thurston’s medical records. Fluid and nutritional intake is an important part of the clinical picture. Fentanyl, diamorphine and midazolam could impair Miss Thurston’s ability to eat and drink.
- The Panel has not seen any document in the medical records to show that the nurses took into account the possible side effects of morphine when noting Miss Thurston’s condition.
- The Panel has not found any document in the medical records to show any evidence of bronchopneumonia.
- The Panel has not found any document in the medical records to show that any discussion took place with Miss Thurston’s family or carers about her treatment.
- Miss Thurston died approximately eight hours after the first, large and only dose of diamorphine.
Salisbury Palliative Care Services, 1995. The Palliative Care Handbook: Guidelines on clinical management, third edition.