Wednesday, 28 August 2013

Liverpool Care Pathway - The Prequel

Nurture may instil; nature will reveal…
Compassion is something you may learn but it may not be taught.

In July 1967, already, the thought was firm in mind, the warning shots were being fired, the social architects were readying their plans:


Mr Patrick Gordon Walker 
Commons — July 11, 1967

One of the results of debates such as this—we have had a number on this subject—is that it has become generally understood, and is almost a truism, how rapidly the elderly population is increasing and will continue to increase. It is probable that by the 1980s there will be about 10 million people over retirement age, and between now and the 1980s—this is a very serious problem for those who have to plan the development of the social services—the proportion of the dependent population—those under school-leaving age, on the one hand, and those over retirement age, on the other—will be rising much more rapidly than the working population, which has to produce the wealth from which we pay for social security.
The Neasden Care Pathway -

In November of that year, discussion in the Commons centred round a BBC report into a culling policy of the elderly at Neasden Hospital in north London.

Commons Sitting of 6 November 1967 Series 5 Vol. 753

  2. Elderly Patients (Resuscitation) 323 words             cc618-9
Commons — November 6, 1967
asked the Minister of Health whether he will make a statement on the policy of the National Health Service on the resuscitation of elderly patients.

Elderly Patients (Resuscitation) 

Commons — November 6, 1967
asked the Minister of Health what is his policy on the resuscitation of elderly patients.

Elderly Patients (Resuscitation) 

Mr Kenneth Robinson 
Commons — November 6, 1967
Yes, Sir. The professional advice which I sought as a matter of urgency is that no patient should be excluded from consideration for resuscitation by reason of age or of diagnostic classification alone, without regard to all the individual circumstances. Any form of general instruction is wholly unacceptable. In each individual case, the decision to attempt resuscitation must remain the responsibility of the doctor immediately in charge of the patient. This advice has been made known throughout the hospital service.

Elderly Patients (Resuscitation) 

Commons — November 6, 1967
While I express appreciation for the right hon. Gentleman's statement, which will do something to allay the very real anxiety amongst the public on this question, could not some further direction be given that it is the duty of the profession to resuscitate patients unless there are very strong indications to the contrary?

Elderly Patients (Resuscitation) 

Commons — November 6, 1967
I think that there has been some anxiety but I also think that there has been a good deal of misunderstanding about the matter. I am advised that only a very small number of hospital patients are affected by cardiac arrest - which is what we are talking about - in circumstances in which it would be possible to take measures which could be effective in reversing the process of restarting the heart.
Commons — November 6, 1967
Will my right hon. Friend convey this information to the B.B.C.? Is he aware that the publicity given to its inquiry into a hospital at Neasden in my constituency has given unnecessary anxiety to many senior citizens in my constituency and has crucified Dr. Twining McMath who is one of the finest physicians we have had?
Commons — November 6, 1967
I think we have kept in touch with the B.B.C. about the progress of this matter.

The BBC report that prompted this brief encounter in the Commons featured in the BBC Tomorrow's World programme on September 20, 1967.

Tomorrow's World was a popular BBC science series presented by the popular duo, Raymond Baxter and James Burke. Baxter, a wartime spitfire pilot, would have scoffed at today's health and safety obsessed world and famously appeared on the programme donning a bullet-proof jacket and having live ammunition fired at him to prove its veracity.

The report in question  concerned the Physician Superintendent at Neasden Hospital, Dr. W. Twining McMath. On May 16 the previous year, Dr. Twining McMath issued a General Memorandum. This concerned patients who were not to be resuscitated (N.T.B.R.).

The report focussed on the fact of the N.T.B.R. directive in itself. The matter of import and significance was the part of the Memorandum which singled out to whom the directive should apply.

In the event of respiratory failure or cardiac arrest, the N.T.B.R. was to apply specifically to elderly patients over the age of 65 years and in the particular cases of "malignant disease; chronic chest disease; chronic renal disease".

Not worth saving...

Neither was Neasden Hospital. In the mid 80's, it was shut down and the land sold off.

These Commons exchanges took place in 1987 -

Neasden Hospital 

Mr Laurie Pavitt 
Written Answers — February 11, 1987
asked the Secretary of State for Social Services how many of the nurses and other National Health Service staff evicted from their homes at Neasden Hospital in December...

Hospital Sales (Brent) 

Mr Paul Boateng 
Written Answers — December 15, 1987
To ask the Secretary of State for Social Services (1) what was the total sum realised by the sale of Neasden hospital by the Brent district health authority; what was the amount allocated by the...
The memorandum, that stood in place and was enforced for nearly a year and a half, was rescinded by Kenneth Robinson, the Minister for Health, following the adverse publicity in the media.

But was it?

The Patient Self-Determination Act of 1990 attempted to advance the idea of the Advance Directive.

A question that same year concerning facilities available to Members of the House invoked this response -

First Aid 

Mr Geoffrey Howe 
Written Answers — April 5, 1990

Fifty members of staff of the House, 127 police officers, 108 security officers and 12 members of the fire section are trained in first aid including resuscitation techniques...
No worries about not being resuscitated in the House, then...

Douglas French was moved to ask:

Heart Attacks 

Mr Douglas French 
Written Answers — May 1, 1990

To ask the Secretary of State for Health whether his Department has issued any guidelines to local health authorities about the resuscitation of elderly heart attack victims.
But was assured:

Mr. Freeman
No. The treatment of an individual patient is a matter for the clinician responsible for his or her care.

In 1992, the Law Lords ruled that withdrawal of feeding tubes can be lawful. Furthermore, the BMA ruled that such artificial means of feeding is a treatment. Nutrition and hydration are as essential to life as the oxygen we breathe. These are not treatments but particulars that are essential to sustain us in life. It is a treatment which affects the course of a disease or affliction. What nonsense do these starched prigs spout!

So, to convey food or liquid to someone unable to partake of these of themselves is a treatment. So, to spoon-feed is also a treatment! To deny thus the essentials to sustain life through an intentional act is to intentionally deprive of life. 

That memorandum, that stood in place and was enforced for nearly a year and a half and was rescinded by Kenneth Robinson, the Minister for Health, following the adverse publicity in the media was still covertly cherished and cultivated by that infamous triumvirate of the GMC, the NHS and the DoH.

And the Gosport killing wards of the Barton Care Pathway followed, contemporary with the curious events that proceeded at Bedford General Hospital.

These more recent exchanges -


Care for the Elderly 

Lords — January 19, 2000
My Lords, I thank the Minister for that Answer. But does he agree with what I perceive to be a frightening practice of asking elderly patients entering hospital whether they wish to be resuscitated...
Frightening. Yes, frightening. This plea was made on these pages -
My sister who is suffering from chronic pulmonary diseases Was shocked when her doctor turned up with a pathway pack intravenous syringes to administer drugs to aid her death She we know is suffering from a chronic disease but her facilities are all perfect she I'd frail but can get to toilet unassisted and is now eating well. This shock as set her back as she it'd afraid her life will be taken if she gets an infection which occurs often in such cases We need help prevent this excalting.
Frightening. Mr. Lamb, there are people living in fear. What an image does this conjure up? A trench coated figure arriving at the door at night with a bag of paraphernalia. This is the Exorcist come, not to exorcise the evil spirit possessing lurking within, but to drain the last dregs of life from his patient!

Baroness Miller asked:

Hospital Patient Resuscitation Guidelines 

Baroness Miller of Hendon 
Written Answers — February 17, 2000
asked Her Majesty's Government:What are the "national guidelines" adopted in National Health Service hospitals for soliciting "do not resuscitate" instructions from elderly but apparently mentally competent patients...
Lord Hunt of Kings Heath 
Applicable guidelines on Decisions Relating to Cardiopulmonary Resuscitation were first published in 1993 in a joint statement issued by the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing. A revised version was published in June 1999. The joint statement gives only general guidelines on the basic principles within which decisions regarding local policies on cardiopulmonary resuscitation may be formulated. It makes clear that all acute hospital trusts should establish local resuscitation policies. The wider ethical context on end of life decisions (of which cardiopulmonary resuscitation is an example) is contained in the BMA guidelines on Withholding and Withdrawing Life prolonging Medical Treatment.

And this from Paul Burstow -

Age Discrimination (NHS) 

Mr Paul Burstow 
Commons — May 15, 2000
The first step in eradicating age discrimination in the NHS is an acceptance that ageism exists at all levels of the health service. The Minister will know that the concerns I expressed this evening are echoed by Members on both sides of the House. Indeed, his hon. Friend the Member for Shrewsbury and Atcham (Mr. Marsden) introduced a ten-minute Bill, the Health Care Standards for Elderly Persons Bill, only last month to press the case for an independent national inquiry. I certainly believe that such an inquiry would have a part to play in addressing the concern felt by many outside the House.
As one of the sponsors of the hon. Gentleman's Bill, and as a co-chair of the all-party group on ageing and older people, I believe that the issue needs urgent attention. Both Age Concern and Help the Aged have collected evidence of ageism in the NHS, and the number of cases rose steadily. In its report "Turning your back on us", Age Concern discussed the findings of a Gallup poll carried out in March last year. It found that one in 20 people over 65 had been refused treatment, while two in 20 felt that they had been treated differently since they turned 50.
Even the Department of Health has found evidence of discrimination. A review of renal services revealed that as many as two thirds of kidney patients over 70 had been refused dialysis or transplants. More recently, the spotlight has fallen on the use of "not for resuscitation" orders. The British Medical Journal recently drew attention to a gap between guidelines and practice in the use of such orders. An article in the issue of 29 April refers to an independent review. Following a complaint by the family of an elderly woman who had died in hospital, the review stated: It was hard to avoid the conclusion that the treatment plan…was to do little more than allow the patient's life to ebb away. At no point had the family or the patient been consulted about the decision to mark the hospital records "not for resuscitation".

Research has found that more than two out of three patients with NFRs are not involved in making that decision. More worrying still is the finding that labelling patients "not for resuscitation" makes them 30 times more likely to die—and with no say in the decision. That cannot be right or acceptable. I hope that the Minister will be able to say something about what the Government are doing to stamp out such an immoral practice.

The need for action at all levels of the NHS to tackle ageism was brought home to me by the case of Mrs. Marge Terry. When Mrs. Terry, described as an "elderly and alert lady", was admitted to St. Helier hospital last September with breathing difficulties, she had every reason to expect to be quickly discharged and back in her home at Bawtree house, a residential home in my constituency. Mrs. Terry, who was 91-years-old, never recovered. After four weeks and five ward changes, she died.

A catalogue of neglect has prompted Mrs. Terry's daughter, Mrs. Eileen McAndrew, to speak out. During those four weeks, the NHS let Mrs. Terry down. Cleaning was inadequate. Bedside cabinets and tables were left sticky and dirty. Bins were left full to overflowing with tissues and other waste. Her records were not kept properly. Address details were wrong. Her age was recorded incorrectly three times in the same notes. She was left sitting in bed in a nightdress and bedjacket badly soiled with blood.

Mrs. Terry waited four days to see a doctor after developing a serious chest infection and a further two days for an X-ray. Soiled bandages were left lying on her bed. She was given little help with eating and drinking. As a result, food was left to go cold. Staff blamed her for that, describing her as unco-operative. She was even left to take her own medication.

On Saturday 9 October, the hospital phoned Mrs. Terry's daughter to come in as quickly as possible. Sadly, Mrs. Terry died minutes before she could get there.

Mrs. McAndrew put it in the following terms: In the four weeks my Mum was in St Helier Hospital, I saw her deteriorate from an elderly alert lady, who used an electric wheelchair and kept me on my toes, to an old frail weak 91 year old going on 100, who kept asking me to take her out of here. I was very disturbed by Mrs. Terry's death. I have already raised the case with the Epsom and St. Helier NHS Trust chief executive, Nigel Sewell. It is clear from the correspondence that the trust has acknowledged that not everything it did for Mrs. Terry was up to scratch. Although the trust has taken a number of steps to improve its procedures, no older person in hospital should be treated like Mrs. Terry. The care and attention to detail that are essential to promoting recovery were missing. The trust management needs to ask some searching questions. Why was she not properly fed? Why was she left to wait for so long before a doctor saw her?

This was also the year the Shipman Care Pathway surfaced to public view. Poor Harold, shot in the eye by the arrow of his own enthusiasm.


Age Equality Commission Bill
Mr Andrew Rosindell 
Commons — November 23, 2001
It is difficult to find a single document on the subject that does not already demonstrate how the elderly are treated differently in terms of the job market, access to health care and travel insurance, to name just a few examples. None of those groups is shy in putting forward its ideas on how issues can be resolved. Considering that our very large civil service is more than able to consult them, I am puzzled as to why we need to spend yet more taxpayers' money on yet another body to tell us what existing structures should be competent enough to work out for themselves. Indeed, we in this Chamber are elected to represent our constituents and to raise these issues. I do not believe that it will help to create yet another body of bureaucrats to speak up for the older population when that is what we are elected to do. The commission is unnecessary if Members of Parliament do their jobs properly.
One area in which there is a clear need for urgent action, however, is the national health service. The number of people who write to me and come to my weekly surgeries to complain about the national health service is staggering, something with which I am confident every Member in this place is all too familiar. It demonstrates the depth of crisis and disarray in the health service.

What most disturbs me and should, I believe, concern every Member of the House is the attitude seemingly shown towards our old folk. It is all too common to hear of elderly patients being treated as if they were second-class citizens. I find that utterly unacceptable and shameful. For example, Age Concern reports that it receives a call a month from people reporting how their clinical notes, or the notes of ageing relatives, were marked "not for resuscitation".

Age Equality Commission Bill 

Mr Paul Burstow 
Commons — November 23, 2001
We rely too much on people's date of birth, which can blind professionals and others to their uniqueness. For example, it can lead to arbitrary decisions about access to health care. In the case of not-for-resuscitation orders, it can determine who lives and who dies. 
What most disturbs me and should, I believe, concern every Member of the House is the attitude seemingly shown towards our old folk. It is all too common to hear of elderly patients being treated as if they were second-class citizens. I find that utterly unacceptable and shameful. For example, Age Concern reports that it. receives a call a month from people reporting how their clinical notes, or the notes of ageing relatives, were marked "not for resuscitation".

Age Equality Commission Bill 
Mr. John Whittingdale
Commons — November 23, 2001
I have focused on the employment aspects, but the Bill covers other aspects, some of which have been mentioned in the debate. I am sure that we all share the views of the hon. Member for Brighton, Kemptown (Dr. Turner) about evidence of age discrimination in the NHS, and the appalling stories of "Do not resuscitate" notices. Nobody could condone that.

Patients' Protection Bill [H.L.] 
Lords — March 12, 2003
Baroness Knight of Collingtree 
My Lords, I beg to move that this Bill be now read a second time. 
On the face of it, it is incredible that a Bill such as this should be necessary. Surely patients in hospital are always given such basic necessities as food and fluid? Well, no. I am afraid that sometimes they are riot, especially if they are old and a doctor judges their life to be useless.

"Patient Protection"? Surely not... The Baroness is correct. That such a Bill should become necessary is demonstrable of the extent of the betrayal by the medical profession.

The years of the LCP followed


Confidential Inquiry into Premature Deaths of People with Learning Disabilities.

BBC News Bristol
The report was commissioned following events at Winterbourne.

The CQC had betrayed its tasked purpose to investigate properly reports of abuse.

At Winterbourne, in 2011, the scandal broke.

Almost fifty years ago, a book was published that shook the NHS and fired a blast that caused a stir of debate in the House.

The book: "Sans Everything" by Barbara Robb.

And that brings us full circle back to the events of 1967...


Mr Nigel Fisher 
Commons — July 11, 1967

Does the right hon. Gentleman mean to refer to the "Sans Everything" issue, which has arisen so recently?


Mr Nigel Fisher 
Commons — July 11, 1967

I am sorry to interrupt again but there is one point which the Minister did not mention in talking about "Sans Everything". Could he categorically confirm that he will give the protection of...


Mr Kenneth Robinson 
Commons — July 11, 1967

These allegations, contained in a book called "Sans Everything", are for the most part made pseudonymously. I have made it clear in the House, in answer to Questions, and my...


Mr Philip Goodhart 
Commons — July 11, 1967

which have been made in the book "Sans Everything" and will investigate any specific allegations which are made...


Mr Airey Neave 
Commons — July 11, 1967
book, "Sans Everything". It is important that we should be objective about the statements made in the book. I want first to deal with the suggestion of an inspectorate of mental hospitals.


Mr Leslie Huckfield 
Commons — July 11, 1967

The publication "Sans Everything" goes about this in the wrong way, because it should not only give serious examples and quote speeches and comments to give a headline effect.


Dr Shirley Summerskill 
Commons — July 11, 1967

the National Health Service. There was a danger that today's debate would end in a series of generalisations and perhaps be based solely on the book "Sans Everything".


Miss Joan Vickers 
Commons — July 11, 1967

of his people who are engaged in research work to see the people in the centre of Russia who seem able to enjoy life at 110 years of age. Recently, there has been much publicity given to the book "Sans Everything"...


Mr John Eden 
Commons — July 11, 1967
's feelings, other people's particular whims or the situation in which they may happen to find themselves. The Minister of Health was right to approach this question of the book "Sans Everything"...


Mr Bernard Braine 
Commons — July 11, 1967

Doctor Stephen Horsley, whom I have had the pleasure of meeting and who is quoted in "Sans Everything", believes that "Perhaps 80 per cent. of elderly...

Book, "Sans Everything" (Committees of Inquiry) 

Mr William Van Straubenzee 
Commons — November 6, 1967
asked the Minister of Health when he expects to complete his inquiries into the allegations of cruelty to old people contained in the book "Sans Everything".
The blast continued to reverberate into 1969...

"Sans Everything" (Inquiry) 

Mr Maurice Macmillan 
Commons — March 19, 1968
asked the Minister of Health when the official inquiry which was started after the publication of "Sans Everything" is expected to be completed; and whether he will publish a full report.

Book "Sans Everything" (Inquiry) 

Mr Benjamin Whitaker 
Written Answers — May 17, 1968
asked the Minister of Health, when he expects to receive and publish the findings of the committees of inquiry which were appointed as a result of the book, "Sans Everything."

Sans Everything 

Mr Benjamin Whitaker 
Written Answers — June 25, 1968
asked the Minister of Health whether he will make a statement on the progress of the inquiries into the allegations in Sans Everything; and when he expects to publish the results.

Book, "Sans Everything" (Reports of Inquiries) 

Mr Maurice Macmillan 
Commons — July 16, 1968

asked the Minister of Health when he expects the report on the inquiry into the allegations in "Sans Everything" to be published.

Book "Sans Everything" 

Mr Jack Ashley 
Written Answers — July 25, 1968
asked the Minister of Health whether he has referred the reports of the Committee of Inquiry on the book, "Sans Everything", to the Working Party on Geriatric Hospitals which he set up in 1965...

"Sans Everything" 

Mr Eric Moonman 
Written Answers — January 28, 1969
asked the Secretary of State for Social Services what was the cost of the six committee inquiries into the book, "Sans Everything", and other related items of expenditure.

"Sans Everything" 

Mr Benjamin Whitaker 
Written Answers — April 16, 1969

asked the Secretary of State for Social Services which of the criticisms made by the reports of the inquiries into the "Sans Everything" allegations have not yet been rectified.

"Sans Everything"...? 
From the seven ages of man -
As You Like It

Act 2, Scene 7, Page 7

Seeking the bubble reputation
Even in the cannon’s mouth. And then the justice,
In fair round belly with good capon lined,
With eyes severe and beard of formal cut,
Full of wise saws and modern instances;
And so he plays his part. The sixth age shifts
Into the lean and slippered pantaloon
With spectacles on nose and pouch on side,
His youthful hose, well saved, a world too wide
For his shrunk shank, and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.

Bibliographic information

The Foreword reads:
Institutions develop powerful instruments of defence for their protection and perpetuation. Sometimes their officers or governing bodies lose sight of the primary purpose for which they were planned and their energies become deployed in rituals or personality conflicts. The purpose becomes subordinated to the personnel.


    The Review Inquiry whitewash -

Allegations Concerning the Care of Elderly Patients in Certain Hospitals
Presented to Parliament by the Minister of Health by Command of Her Majesty July 1968
7s. 6d. net Cmnd. 3687
In Section 1 of the book “Sans Everything” (published in June, 1967, on behalf of the Association for the Elderly in Government Institutions) a number of contributors gave their views on the conditions under which elderly patients are cared for in some National Health Service hospitals. In her Preface to the book, the Chairman of AEGIS indicated that the descriptions were applicable to a small minority of hospitals. Nevertheless, they gave rise to much public concern, and were of a nature which clearly called for investigation.

At the request of the Minister of Health, the Hospital Boards within whose responsibility the hospitals concerned lie appointed independent Committees of Enquiry to investigate the allegations made in Chapters 3, 5 and 6 of “Sans Everything”, and also to enquire into the present state of affairs at these hospitals. Seven hospitals were involved, in six hospital regions. One Committee of Enquiry was also asked to investigate allegations of ill-treatment of patients in one of these hospitals which were reported in the Press at about the same time.
The Chairmen of these Committees were Queen’s Counsel whose names had been suggested by the Lord Chancellor at the request of the Minister of Health; the other members of each Committee were a doctor, a nurse and one or more persons not professionally qualified in medicine or nursing but experienced in the administration of hospitals or other public concerns. None of the Chairmen or members of any Committee had any connection with any hospital authority in the Region in which the hospital with which his Committee was concerned is situated.

The findings and recommendations of these Committees of Enquiry are reproduced in the following pages in accordance with the undertaking given to Parliament on behalf of the Government in the Debate of llth July, 1967, on the Care of the Elderly. As in the book, the identity of the authors of the allegations and other persons is concealed by the use of pseudonyms. In the book the hospitals were also referred to by pseudonyms but their names are now given at the head of the relevant Report.


    More than half a century has slipped past...

  1. Eleven arrests over Nottingham care home death | Social Care Worker
Eleven people have been arrested on suspicion of the manslaughter of an 86-year-old woman at a Nottinghamshire care home.Ivy Atkin died on 22 November 2012, shortly after she moved out of Autumn Grange care home in Sherwood Rise.Nottinghamshire Police said five men, aged between 37 and 77, and six women, aged between 19 and 52, had been arrested.The home closed in 2012 when its council contract was suspended. 13 Aug 2013 - Eleven people have been arrested on suspicion of the manslaughter of an 86-year-old woman at a Nottinghamshire care home. Ivy Atkin died ...
  1. Health care worker held as Scotland Yard makes 71st Operation ...
7 Aug 2013 - Press Gazette, Britain's Journalism Weekly: news, analysis and jobs.
  1. BBC News - Nurses arrested in Hillcroft care home abuse inquiry
10 Oct 2012 - Six care workers have been arrested in connection with suspected abuse of elderly residents at a care home near Lancaster, police say.
  1. Winterbourne care home: More arrests over alleged abuse - BBC
7 Jun 2011 - Police investigating alleged serious abuse at a care home near Bristol ... A support worker stands on a patient's hand as she is restrained.
  1. Manchester care home worker arrested over murder of resident | UK ... › NewsUK newsManchester
27 Mar 2013 - Investigation launched after Victoria nursing home resident Ivan Emmanuel Campbell, 73, dies in hospital.
  1. BBC Panorama care home investigation: four arrested - Telegraph › Health1 Jun 2011 - Police have arrested four people after amid allegations that carers ... We are working with the primary care trusts and councils who pay for the ...
  1. Eleven arrests over care home death - Telegraph › HealthHealth News13 Aug 2013 - Eleven people have been arrested on suspicion of manslaughter ... retired nurse who accepts that there are people working in the 'Care' sector ...
  1. Social Care TV: Children of prisoners: arrest
Social Care TV: Children of prisoners: arrest. There is no flash ... find this useful? Social workers, probation officers, family support workers, parents, teachers.
  1. Abuse inquiry at The Granary care home in Wraxall - two people ...
6 Feb 2013 - POLICE have arrested two workers at a care home following allegations of abuse against a patient. The care workers at The Granary in Lodge ...
  1. 11 bailed after care home death - ITV News -
13 Aug 2013 - A whistleblower who worked at a care home where 11 former workers were arrested yesterday on suspicion of manslaughter has told ITV News ...

2013 sees the launch in the States of the 5 C's Campaign...
and, in the UK, the 6 C's Campaign.

NHS England


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