Liverpool Care Pathway - The Three Options: A Post-modern Fairytale

Once upon a time, there were three options. There was a mega-ginormous option, a not so ginormous option and a little baby option...


This is the The Portsmouth News –

THE families of patients who died at a Gosport hospital have three inquiry options to get the answers they want.

Yesterday, families met health minister Norman Lamb to discuss the findings of the Baker report and how to move forward.

The report looked into deaths at the Gosport War Memorial Hospital in the 90s.

As reported, Iain Wilson, 53, of Beryton Road, Gosport, was one of the people who visited Mr Lamb.

Mr Wilson’s father Robert, 74, had been to Queen Alexandra Hospital, in Cosham, for a shoulder injury.

He was transferred to GWMH, to wait to be put into a nursing home.

But he died in October 1998, and the cause of death was put down to bronchopneumonia.

Mr Wilson said: ‘It was a good meeting, but nothing was decided.

‘It was left wide open to see what will happen next.’

Yesterday, families were told they could ask for a full public inquiry, a full independent investigation, or an independent panel, similar to the Hillsborough investigation.

‘I have always said there should be a full-on public inquiry and a criminal investigation,’ added Mr Wilson.

‘A full inquiry would be very long-winded and expensive, so I don’t know which way it will go.’

The Baker report looked into 81 deaths during the 90s, after concerns were raised about patient care under Dr Jane Barton. It revealed an over-prescription, and in some cases over-use, of opiates, and that note-taking had been poor.

Richard Baker, a professor of clinical governance, who worked on the Harold Shipman inquiry, started his review in 2002.

The government would not publish the report until the final inquest into deaths from that period took place earlier this month.

Gosport MP Caroline Dinenage said: ‘I would prefer option two or three, rather than a full inquiry.

‘It would be expensive and distressing for families.’

'Expensive and distressing'. Caroline, they want what they have been fighting for all these years. JUSTICE!

They hid the Baker Report away for ten years.

They said they had to await the outcome of the inquests.

They held that process up as long as they could by denying funding.

They said it was not of ‘national importance’. What’s that got to do with anything? Murder is murder...

Eventually, they connived to release it, buried under the hype of the publication of the flawed LCP Review and the weekend news.

Why…? What are they trying to hide?

The Barton Method is now applied as part of the GSF and adopted in general practise. Was Gosport the prequel of the LCP?

Does that sound bizarre, far-fetched?

Outline of a script for a Monty Python sketch –

Scene: An elderly woman lies in her hospital bed. An EoLC nurse is talking to two young women, the elderly woman’s granddaughters. He is telling them their grandmother is dying and discussing the funeral arrangements. He is delicately asking them to consider how they are going to break the news to their daughters. The two young women are in distress, in denial. This cannot be… A voice intervenes: “Ooh, aren’t you lovely?” The elderly woman continues: “You’ve got lovely eyes.” She is flirting with the EoLC nurse.

Of course, this could not really happen. It’s surreal. It’s on a par with the ‘Parrot’ sketch.

But it did happen. The elderly lady, Kathleen Vine, is pictured here with her granddaughters, Helen and Alison, on BBC News Health –

It is surreal. It is bizarre. It happened.

If Kathleen had not woken when she did, she would have perished on the EoLC Pathway. She would have died, but that's okay because that is what they diagnosed would happen and that is what people tend to do on these EoLC Pathways. They die.

She would have died, but she was not dying. It would have been murder. They would have got away with murder. The perfect crime. What did happen, though, is surely an act of attempted murder...?

They connived to release the Baker Report buried beneath the hype of the publication of the flawed LCP Review and the weekend news.

Then, The Independent reported -

An independent inquiry into the deaths of dozens of elderly patients given "life-shortening" powerful painkillers at a Hampshire hospital will be announced by ministers within weeks.

At last... An investigation into the programme to limit life at Gosport...

Then it gets watered down to 'three options'! They are still trying to hide something. Whatever could it be...?

This is the World Medical Times –

Today, hooking people up to syringe drivers features as common practise in palliative care.

These are Nurse Giffin's words as reported by Richard Kimble:

I worked happily at the unit and felt we treated the patients well based on love & care. However this all changed when Gill Hamblin took over and encouraged syringe drivers. Prior to her coming we rarely used a syringe driver and when she came they escalated.

Dr Barton asked my opinion once about a patient Sister Hamblin wanted to start on a syringe driver and I said it was unfair and she should go back on Valium/Diazepan and she lived for a further 10 years.

I would like to add that I worked on nights at the Annex for 10 years before someone died on nights. However once Sister Hamblin arrived it became a regular occurrence and I can remember the ambulance drivers joking about it.

Links to original documents are also provided.

Here and here –

Some staff feared that it was becorning routine to prescribe diamorphine to patiients that were dying regardless of their symptoms. AII staff agreed that if they had concerns in future related to theprescribing of drugs they would approach Dr. Barton or Sister Hamblin in thefirst instance for explanation, following which if they were still concerned they could speak to Dr. Logan. Mrs. Evans stated she would also be happy for staff to talk to her if they had any problems they wanted advice on. With no further points raised, Dr. Barton, Dr. Logan, Sister Hamblin and S.N.Barrett left the meeting to commence Ward rounds. Mrs. Evans spoke to Sister Hamblin and S.N. Barrett the following morning to ask them to organise day staffs’ views and ask them to make every effort to ensure patients assessments were both objective and clearly recorded in ­­­nursing records"

In this 1991 document, Dr. Logan is the Consultant Geriatrician; Dr. Barton is the Clinical Assistant.

These are notes of a meeting held on 17th December 1991 for staff who had concerns about the use of Diamorphine within the unit.

The subject is described as both 'sensitive and emotive'.

Problems Identified on 31 October 1991  

1. Staff Nurse Giffin reported that a female patient who was capable of stating when she had pain was prescribed Diamorphine via syringe driver when she was in no obvious pain and had not complained of pain. 

2. Staff Nurse Giffin reported that a male patient admitted from St Mary's General Hospital who was recovering from pneumonia, was eating, drinking and communicating was prescribed 40 mg Diamorphine via a syringe driver together with Hyoscine, dose unknown, over 24 hours. The patient had no obvious signs of pain but had increased bronchial secretions. 

3. Staff Nurse Tubbritt reported that on one occasion a syringe driver "ran out" before the prescribed time of 24 hours albeit that the rate of delivery was set at 50 mm per 24 hours. 

4. The staff are concerned that Diamorphine is being prescribed indiscriminately without alternative analgesia, night sedation or tranquilisers being considered or prescribed. 

5. Nurse Tubbritt, reported that a female patient of 92 years awaiting discharge had 1.m. 10 mg Diamorphine at 10.40 hours on 20.9.91. and a further 1.m. 10 mg Diamorphine at' 13.00 hours on 20,9.91.administered for either a manual evacuation of faeces or an enema. 

6. There are a number of other incidents which are causing the staff concern but for the purposes of this report are too many to mention. The staff are willing to discuss these incidents. 

7. It was reported by Staff Nurse Tubbritt that: 

a) 42 ampoules of Diamorphine t0 mg were used between 20 April 1991 -15 October 1991. 

b) 57 ampoules of Diamorphine 30 mg were used between 15 April 1991 -15 October 1991 (24 of the 57 ampoule s of Diamorphine 30 mg were administered to one patient, who had no obvious pain, between 9 September 1991 and the 21 September 1991). 

c) 8 ampoules of Diamorphine 100 mg were used between 15 April 1991 - 2' September 1991 (4 of the 8 ampoules of Diamorphine 100 mg were administered to the patient identified in 7b above, between 19 September 1991 and the 21 September 1991).  

Note - This patient had previously been prescribed Oramorph 10 mg in 5 ml oral solution which was administered regularly commencing on 2 July 1991. The staff cannot understand why the patient was prescribed Oramorph and Diamorphine. When the staff questioned the prescription with Sister they were informed that the patient had pain. The staff recalled having asked the patient on numerous occasions if he had pain, his normal reply was no.  

Conclusion 

1. The staff are concerned that Diamorphine is being used indiscriminately even though they reported their concerns to their manager on 11 July 1991 (appendix). 

2. The staff are concerned that non opioids, or weak opioids are not being considered prior to the use of Diamorphine. 

3. The staff have had some training, arranged by the Hospital Manager,namely :- 

The syringe driver and pain control-  Pain controI Staff Nurse Tubritt wrote to Evans the producers of Dianrorphine and received literature and a video - Making Pain Management more Effective.

Letter from the Branch Convener to the District General Manager at St. Mary’s hospital praising restraint of staff and expressing concern for patients, relatives and staff.

“A majority of the day staff have left over the period of two years that this situation has been present, whether this was a reason for their leaving I am unsure.”

Concern is also expressed that the matter could be leaked to the media.

New practises. New procedures. Pre-emptive prescribing.

We have come a long way. EoLC Pathways. Soul Midwifing. The Barton Method is now part of the GSF.

In what Ike might have called a Medical-Pharmaceutical Complex, the NCPC offers 'Corporate Partnerships'.

One of these is with Napp Pharmaceuticals -

The DoH EoLC Strategy -

NCPC worked closely to develop the strategy and we are a member of the Implementation Advisory Board. - NCPC

Richard Kimble further reports in the World Medical Times – 

Having read the Transcripts of the Coroner’s Inquest and the Transcripts of the GMC Hearing, a crucial drug was omitted from the charges even though it was so dangerous to Patient K / Mrs Elsie Devine than any other administered to her. Discussing this drug during the proceedings failed to give the impact it would have had if it had been added to the charges.

I will reiterate that Mrs Devine, an opiate naive patient woke on the morning of the 19th November 1999 feeling the effects of a 25mg Fentanyl Patch running at full strength (Equivalent to 135mg of Morphine). In her agitated state of mind she was held down and injected with 50mg of Chlorpromazine but this drug was not mentioned in the charges against Dr Barton, even though it was capable of ending Mrs Devine’s life. (Cardiac Arrest)

There is no apparent mention of Chlorpromazine in the recently published Gosport Review, Final version, October 2003.

- RCN Dementia Guide

Chlorpromazine was a first generation antipsychotic in use at that time to treat dementia. Thus, to control this poor lady's agitation, Chlorpromazine was added in to the mix.

The Review does make reference to the CHI (Commission for Health Improvement) Investigation published in July 2002 -

CHI has serious concerns regarding the quantity, combination, lack of review and anticipatory prescribing of medicines prescribed to older people on Dryad and Daedalus wards in 1998. A protocol existed in 1998 for palliative care prescribing referred to as the “Wessex guidelines”; this was inappropriately applied to patients admitted for rehabilitation.

Anticipatory prescribing, patients admitted for rehab downsized to palliative care...

The Wessex Guidelines, a precursor to the Liverpool Care Pathway...

The Barton Care Pathway.

4.4 The experts commissioned by the police had serious concerns about the level of use of these three medicines (diamorphine, haloperidol and midazolam) and the apparent practice of anticipatory prescribing. CHI shares this view and believes the use and combination of medicines used in 1998 was excessive and outside normalpractice.

These three medicines used in the Wessex Guidelines are prescribed for use in EoLC Pathways.

CHI welcomes the introduction and adherence to policies regarding the prescription, administration, review and recording of medicines. Although the palliative care Wessex guidelines refer to non-physical symptoms of pain, the trust’s policies do not include methods of non-verbal pain assessment and rely on the patient articulating when they are in pain.

They can look at you and, via intuitive assessment, 'know' you are going to die. That is the essence of the GSF Surprise Question; that is the Barton Method. They interpret that nuance of tone, that expression. We have come a long way.

But let us go back to those basic emotions dear Nurse Giffin called love and care. If a picture ever painted a thousand words, this is it.

May the haunted, accusing look on this poor man's face haunt you, Mr. Lamb. May it haunt you in your every dream in the dark of night until you take rightful and forthright action for a full, extensive, no-holds-barred Public Inquiry into this monstrous scandal! Crimes have been committed; charges must be brought.

- Portsmouth News

Further reading -

Liverpool Care Pathway - The Hollow Man

Liverpool Care Pathway - Ten Years In The Waiting

Liverpool Care Pathway - Bring Them All To Heel And Put Them In The Dock

Liverpool Care Pathway - The Trailblazers

Final Word -

Keeping people alive is a costly business

The euthanasia lobby has found growing support on both sides of the House and in both Houses. This isn't just about 'dignity in dying'; it is about digging the economy out of the pensions and benefits black hole into which it is plunging by filling it with the corpses of  the most frail and the most vulnerable members of the community.

Diagnosing dying and putting patients on a pathway sounds like death with dignity but it's going to save governments, and the taxpayers who fund them, a lot of dosh.

Of course it's not about killing people, but it's still cheaper to kill the seriously ill than to keep them alive in hospitals, nursing homes or hospices.

This isn't just about pensions and benefits. Hospitals under financial pressures and bound by targets don’t want bed-blockers clogging the wards eating up finite resources.

Of course there's no dark government plot to murder old people, but deficit-burdened Governments have other considerations. 

Death, particularly for the frail and the fragile elderly, the vulnerable and the disabled in mind or body, is a final and lasting solution.

(- Murder On The NHS Express)