Liverpool Care Pathway – Not Anecdote Nor Chestnut Of Barker Or Raconteur

Neither Tall Tale Nor Urban Legend

When it became clear that we could not obtain justice through the complaints process, we actually approached a number of solicitors. One such solicitor confided to us during the telephone interview that our experience is not at all uncommon in the NHS and a culture has developed of nurses taking it upon themselves - or with tacit approval if not actual collusion of doctors - to determine quality of life, putting people down like pets at a veterinary surgery! She made these comments in response to my account of what had occurred at Caterham Dene. She said any action would be costly and messy; the burden of proof would be on us and not them and that they had both the means and the facility of the backing of peers and of plausible deniability. Suspicion is not evidence, evidence must confirm intent and procedure is not evidence at all.

But still the truth may out.

The Ugly Facts

The Independent reports:

The caring killers: Death by night shift

For years, nurses illegally administered morphine and other powerful drugs. Hospital patients died. Now the story can be told. Nina Lakhani reports

The report reveals that night nurses at the hospital in Keighley, West Yorkshire, openly gave patients drugs such as morphine intravenously for many years, despite the practice being illegal

A showcase hospital that won the Government's highest three-star rating allowed nurses to prescribe illegally and administer powerful drugs which police believe killed three patients and injured many more.

A damning report into "systemic failures" at the Airedale NHS Trust reveals that night nurses at the hospital in Keighley, West Yorkshire, openly gave patients drugs such as morphine intravenously for many years, despite the practice being illegal and against hospital rules. 

Nobody has ever faced trial or been struck off as a result. One nurse at the heart of the inquiry, Sister Anne Grigg-Booth, was charged with three murders, one attempted murder and more than a dozen lesser, related charges but died of an overdose in 2005 before the case came to trial. Her death meant the allegations against her were never tested. No motive has ever been suggested for her actions.

The report, by an independent panel, to be published next week, dismisses claims that the deaths were the work of one "rogue nurse". Grigg-Booth, it states, was no Beverley Allitt, the so-called "Angel of Mercy" who was jailed for life after being convicted of killing four children while working in a Lincolnshire hospital in 1991.

Airedale Trust hospital bosses, the report says, "failed to recognise or act upon the fact Sister Grigg-Booth was part, if not a symbol, of a system that was not working".

The report, a draft copy of which has been seen by The Independent on Sunday, says oversight systems at the hospital, which won national awards for quality, did not fail "overnight" but were "recurring". The trust's governing body was operating in a "parallel universe" completely unaware of what was happening in hospital wards overnight. Senior managers knew, or should have known, but did nothing, it says. "The management did not always reflect back the reality of what was actually taking place at the coalface," it states. Individual staff troubled by events were too frightened to challenge it, believing managers would not act.

The findings will add to mounting pressure on the new coalition government to examine how local NHS organisations are run and by whom, and force ministers to investigate how systemic safety breaches can take place under the noses of NHS bosses and safety watchdogs. It follows similar critical reports of NHS failures at Mid-Staffordshire and Leeds Teaching Hospitals. There are calls for the second Mid-Staffordshire inquiry promised by the former health secretary, Andy Burnham, into the role and effectiveness of regulators in spotting such systemic failures.

Patient safety groups say the public will want to be assured that the impact of any spending cuts on the NHS will be monitored to ensure patient safety remains paramount. Former Keighley MP Ann Cryer said yesterday that it was unsafe for hospital managers to rely on external reports, and they must take a more hands-on approach to find out what is happening on the wards.

The inquiry said night nurse practitioners (NNPs) "ran" the hospital at night after the NHS introduced the New Deal in the early 1990s to comply with European regulations which insisted that junior doctors' working hours had to be reduced. The NNP posts were created to take some of the burden off doctors and ensure night nurses disturbed them as little as possible.

Grigg-Booth was one of them. London-born, she joined the hospital in 1977. Some colleagues described her as hard-working, committed, caring and good in a crisis, others as a "larger than life" person who was the stuff of hospital legend having once brought a parrot on to a ward. Some colleagues, including doctors, found her intimidating and overbearing and accused her of bullying. She rarely attended training sessions, didn't like filling out forms, and got away with both. The report suggests she possessed a cavalier attitude towards management and "seems to have regarded herself as above the rules". According to some staff, Grigg-Booth liked to be regarded as an old-style matron who carried ultimate authority at night.

NNPs took verbal orders for medicines from doctors over the phone to save them coming to the ward. They also administered morphine and other opiates intravenously. Neither was allowed under hospital or professional regulations. Grigg-Booth, and at times other NNPs, also prescribed opiates such as pethidine and diamorphine for patients. This was risky and unlawful as they can hasten or cause death.

Yet no one, not a pharmacist, a doctor or a manager, ever questioned what they were doing, so they carried on believing it was all right. They weren't trying to hide anything: clear, open records of the drugs issued on prescription charts, clinical notes and letters exist as far back as 1996. Opportunity after opportunity was missed because some people didn't notice, while others failed to act. Occasional complaints to the divisional manager went nowhere, and evidence of a "club culture" between key staff existed, according to the report. So the board remained unaware, no doubt reassured by the awards and accolades it was winning as its reputation soared. The inquiry found little evidence of the board debating protocols and policies, and external accolades blindly accepted without the healthy suspicion which is crucial for good management. By failing to find out how the New Deal target was being achieved, hospital bosses inadvertently put the needs of the organisation before the needs of patients, the report states.

The divide between what the board thought was going on and what was actually happening at night is described as a "striking failure". Apart from two visits by the director of nursing in 1995 and 2003, no senior boss visited the hospital at night. The chain of command between the trust board and the night nurses was "effectively broken", the report concluded.

Action was finally taken only after one senior nurse inadvertently spotted the suspicious drug prescriptions while carrying out an internal audit of patient notes in December 2002. The nurse noticed that diamorphine given to Annie Midgley, 96 – to alleviate her distress – was illegally prescribed by Grigg-Booth two hours before Mrs Midgley died. This triggered the police investigation and Grigg-Booth's suspension.

At that time, Grigg-Booth was preparing to return to work after six months off sick. She had been drinking heavily and using a lot of painkillers while ill. She came to A&E demanding drugs on several occasions and there were rumours, but no evidence, of her taking medication from the wards for herself. In August 2004 Grigg-Booth was charged with three counts of murder, including Mrs Midgley, one of attempted murder and 13 counts of administering noxious substances with intent to cause harm. Her case was listed for plea in Bradford Crown Court in March 2006. She died at home alone after taking an accidental overdose of antidepressants on 29 August 2005.

The divisional manager, a nurse by background, kept his job despite documents which strongly suggest he had known what was going on for several years. He resigned only when arrested by police in 2004 and refused to give evidence to the inquiry.

One nurse manager was eventually sacked. Two of the NNPs were downgraded and then left; another resigned. No one else was charged. None of the nurses has faced disciplinary action by the Nursing and Midwifery Council.

The inquiry report praises management improvements at the Airedale Trust since 2005 but pointedly warns of the "enormous time and energy being expended on achieving foundation trust status". "This must not become an end unto itself," the report warns. "Unfortunately there are examples across the NHS where it would appear that the process has beguiled boards into losing sight of their overriding goal of serving patients in the best way possible."

Ms Cryer said yesterday: "If the chief executive of a small district hospital like Airedale had no idea about the things going on under his nose, this could certainly happen in a bigger hospital, unless the right checks are in place. The NHS is wonderful, but when it goes wrong, it can cost lives. Airedale must make sure the right systems are in place and stay in place, so that something like this can never happen again. They must make sure they know how targets are being met, and at what cost." 

How the health service has failed patients

Inquiries into NHS scandals have raised similar issues for years

1998 Dr Jane Barton was found guilty earlier this year of gross professional misconduct for prescribing unjustifiably high doses of painkillers and sedatives to 12 elderly patients at Gosport War Memorial Hospital – nearly 12 years after the first death was investigated by Hampshire Police. Even then, she was not struck off. None of the nurses who administered the drugs has faced disciplinary action.

2002 Nurse Colin Norris killed five elderly patients with the diabetic drug insulin at a Leeds hospital. The subsequent inquiry found safety checks were not embedded in the city's hospitals, and systems to monitor the supply and use of drugs were insufficient, allowing Norris to continue undetected for months.

2008 A target-driven culture and huge spending cuts were crucial in Mid-Staffordshire becoming one of the country's first foundation trusts, but, it turned out, at the expense of safe, high-quality patient care. Positive external reports were accepted while complaints from patients, relatives and some staff never reached the trust board. 

Fourteen trusts identified with high death rates

Jeremy Laurance

Fourteen NHS Trusts were identified yesterday with higher than expected death rates. But Barking, Havering and Redbridge was not among them – its mortality rate was better than average.

A new measure, called a Summary Hospital-level Mortality Indicator (SHMI), is intended to provide an "early trigger to probe potential problems" with the quality of care, according to the Department of Health.

But its limitation was immediately exposed by its failure to highlight the shortcomings at the Barking trust. Officials stressed it was only one indicator and could not reveal all the problems in the NHS.

The new measure monitors deaths in hospital as well as those within 30 days of discharge and is said to be more accurate.

It was developed after the scandal exposed at Mid Staffordshire NHS Trust in 2009, where between 400 and 1,200 excess deaths were not picked up. 

The truth is more ugly and more messy than could it ever have been conceived to be.

The reality is more odious and abhorrent than anyone could have realised.

The fact that the culprits are not served their just deserts bears out what we were told and what we have observed to be the case.

Administration of opiates; denial, withholding and withdrawing of life-prolonging medical treatment; withdrawal of food and fluids…

The truth is that what does go on – and what has gone on for years – now has a valid and plausible cover story:

The Liverpool care Pathway!

Nurse practitioners are deemed to have acted 'illegally' - 

NNPs took verbal orders for medicines from doctors over the phone to save them coming to the ward. They also administered morphine and other opiates intravenously. Neither was allowed under hospital or professional regulations. Grigg-Booth, and at times other NNPs, also prescribed opiates such as pethidine and diamorphine for patients. This was risky and unlawful as they can hasten or cause death. 

Diamorphine use is ‘risky and unlawful’ as it can hasten death.

Morphine and other opiates were administered intravenously –

But not without verbal authority from doctors.

Diamorphine is used and morphine and other opiates are administered intravenously on LCP.

Therefore, LCP is intended to ‘hasten death’.

Therefore, is not LCP euthanasia and not palliative care?

Are these NNP’s ‘Angels of Death’ or ‘Angels of Mercy’? In which manner do they perceive themselves?

Are these NNP’s perceived to be wrong because of their actions or because they have acted without authority and outside of protocol?

LCP is a legal document that provides authority, procedure and protocol.

Procedure provides protection. Could they not follow procedure because that procedure was not in place to follow?

Those taking their final steps along life’s pathway deserve the utmost respect and individual consideration. Dying is a very personal thing at a very personal moment.

Death by induction and by protocol does not provide this.

In a workshop session, ‘The Medicalisation of Dying', led by Professor Aidan Halligan, a former Deputy Chief Medical Officer for England, it was advised to ‘Do the right thing well on a difficult day’. In his introductory remarks, Professor Halligan spoke of the necessity to be personally present to patients – for instance, to hold their hands, to listen to what they had to say, rather than treating them as a number on a list.  A good doctor helps people to rediscover their lost values, and looks after someone because of who they are, with no discrimination, Professor Halligan said.

But this costs time and money. In a dedicated Hospice situation, there may be provision for both but, elsewhere, there is not.

The concern to respect the wishes of the living and of those who wish to live has become second to that of the dying and those who wish to die.

The right to life and the desire to preserve life has been overtaken by the right to death and the desire to promote death as a preferable outcome.

Medical standards must be met and maintained but financial constraint must not be breached.

This is a fine line which cannot be crossed; it is a medical and financial tightrope that enforces a precarious balancing act of resources.

There is an insistent pressure that advance directives to decline treatment be observed -

While the expectation to receive prompt and sympathetic treatment is given scant regard.

Bad and mad financial decisions in capital provision in recent years have put the NHS in financial jeopardy.

Instituting a protocol that promotes death as a positive outcome and making establishment of that protocol a condition of DOH funding under the CQUIN payments system must seem like a financial lifeboat to DOH and NHS Managers, therefore.

That protocol is The Liverpool Care Pathway.