Chapter 4: Healthcare organisations and individuals
Concerns about patient safety at the hospital
At the time that the first recorded concern arose about clinical practice at the hospital in 1991, it was managed by Portsmouth and South East Hampshire Health Authority, as a directly managed unit. Chapter 1 of this Report explains how the nurses raised concerns about the drugs prescribed and used in Redclyffe Annexe. It notes that the meeting on 17 December 1991 appeared to have the effect of closing down the nurses’ concerns. The documents provided to the Panel do not include any further notes or correspondence from this time. The evidence therefore suggests that there was no further action taken in the hospital to follow up the concerns.
As is made clear in an unpublished subsequent external report, in February 2003, “the failure to follow-up the expression of concerns made by nursing staff about prescribing practice in Redclyffe Annexe from 1988 was a negligent act by the Unit Management Team … Managers seem to have placed too much reliance on the unwillingness of junior nurses to speak out in front of GPs at a meeting held on 17 December 1991” (DOH702113, p4).
Between 1992 and the receipt of a complaint following the death of Mrs Gladys Richards in 1998, the only documented activity of even marginal relevance relates to audits of the prescribing of benzodiazepines and night sedation in 1995/96 and 1997, drug cards on Mulberry Ward in 1997, and medical record keeping in 1997 (DOH604186, DOH604182, DOH604184, MRE000139). Although these identified various shortcomings in record keeping and review, there is no discernible link with the previous concerns and none of the audits picked up any other prescribing matters.
Subsequent patient safety concerns
In 1994, hospital and community services in Portsmouth, including Gosport War Memorial Hospital, became part of Portsmouth HealthCare NHS Trust. Although this meant a change of management arrangements and of some managers, there was as elsewhere little change in the approach to assuring patient safety. There is a gap in the documents provided to the Panel relating to Portsmouth HealthCare NHS Trust. From the documents which have been made available, it seems clear that the rise in the inappropriate use of opioids and other drugs over the course of 1994–1998 documented previously in this Report went undetected by the new Trust.
Then, in 1998, a complaint was made about the treatment of Mrs Richards, who died on 21 August 1998. Documents seen by the Panel disclose that the complaint was made verbally to Lesley Humphrey, Director of Quality, Portsmouth HealthCare NHS Trust, and that Sue Hutchings, Investigating Officer, started an internal investigation on 24 August 1998. The investigation report shows that William (Bill) Hooper, the General Manager for the hospital at the time, commissioned the investigation.
The documents further show that the investigation report included reference to medication administered via a syringe driver:
"Sadly, Mrs. Richards’s death was not as [the complainant] had hoped it would be. She felt the use of the syringe driver made her mother become unconscious and she did not say her ‘goodbye’, although both she and her sister were with their mother almost continuously day and night during Mrs. Richards last few days." (DOH604052, p6)
Although this section of the report makes it clear that the syringe driver was one of the elements of Mrs Richards’ care that the complainant was unhappy about, it was not identified as one of the questions raised by the complaint, and the report did not identify the contents of the syringe driver (diamorphine, midazolam, hyoscine and haloperidol). It is notable that Mr Hooper, who commissioned and presumably received the report, was one of the managers involved in the response to the nurses’ concerns over opioid use seven years previously, yet there is no evidence that any link was made.
In August 1998, Mrs Richards’ daughter reported her mother’s death to Hampshire Constabulary, and a police investigation commenced that is assessed in Chapter 5. We could find no documentary evidence that this prompted concern by clinicians or managers over the safety of the Trust’s services.
Although she did not see Mrs Richards during her final admission, Dr Althea Lord was the consultant with responsibility for Mrs Richards’ care. Dr Lord provided a written account for Lesley Humphrey dated 22 December 1998 to pass to the police (DOH604059). The first of Dr Lord’s itemised comments in this account refers to the use of diamorphine via a syringe driver, indicating that this was now a key element of the investigation. Again, however, we could find no evidence that this prompted concern from the Trust, nor that it was linked with the nurses’ concerns in 1991.
Following the completion of the initial police investigation, with no charges being brought, both Hampshire Constabulary and the Trust received further complaints about other patients during 1999. In addition, Hampshire Constabulary informed Max Millett, by now the Trust’s Chief Executive, that the investigation into Mrs Richards’ death was being reopened (DOH604060).
One complaint in 1999 prompted the Trust to seek external advice from Dr Gill Turner, Clinical Services Director of an elderly care unit in Southampton. Although her advice was that “the use of Morphine was entirely appropriate and … the amounts administered could not be considered excessive” (DOH600573, p3), Dr Turner wrote separately to Mr Millett to express concerns about the inadequacy of the consultant cover on Dryad and Daedalus wards and, significantly, about the opioid prescribing regime:
"Whilst recognising that in some of the peripheral units the medical staff providing daily cover are often from outside the hospital, I feel that writing Morphine up for a subcutaneous pump with doses ranging from between 20 and 200 mgs a day is poor practice and could indeed lead to a serious problem. As it happens the nurses stuck to using 20 mgs a day of Morphine in the subcutaneous pump and then increased it up to 40mg but they could of course have increased it up to 200 mgs given the way the chart is written. I think it unlikely that the jump from 20 to 40 mgs made any real contribution to [the patient’s] management, but I think it is still a large jump and steps need to be taken to consider limiting the flexibility of dosage regime." (DOH600527, p2)
The external advice is clear that the practice of prescribing opioids up to a large dose could lead to a serious problem, but the response initially was that this was an agreed protocol, without which “the patient may have to wait in pain while a doctor is called out who may not know the patient” (DOH600522, p1). Lesley Humphrey wrote to the Medical Director of the Trust, Dr Richard Ian Reid, on 29 October 1999 to report a conversation with Dr Jane Barton, the clinical assistant, whose view was that “the system of medical cover makes it difficult to prescribe otherwise”. The email also refers to “our concerns about the harassment clinicians seem to be facing from some complainants”, but notes that “this is our first opportunity to link a complaint into clinical governance – for positive action!” (DOH600523, p1).
In response, Dr Reid produced a draft protocol for prescribing an opioid by syringe driver on 15 December 1999 (DOH600164). The documents do not show when it was implemented. Another pain management protocol was circulated later, in May 2001 (DOH901340). The Panel could find no reference to any audit of prescribing practice or case note review in response to the clear concerns raised by the complaints, the police investigation and Dr Turner’s external advice. Even given that this was the Trust’s “first opportunity to link a complaint into clinical governance", this would have been an obvious response. The peak use of opioids apparent in 1998, could hardly have failed to reveal the nature of the problems.
Instead, when a workshop was held on 27 February 2001 to review the common themes emerging from five complaints about the hospital between 1998 and 2000, the three themes identified were communication with relatives, the attitudes of staff, and eating and drinking. The notes from the workshop make no mention of opioids or prescribing (DOH600915). Dr Barton had resigned her post as clinical assistant on 28 April 2000, citing concerns over “staffing levels that do not provide safe and adequate medical cover or appropriate nursing expertise” (NHE000212, p1).