Medication 'A Factor' In Patient's Death

A coroner has ruled that medication given to an elderly patient at a heavily-criticised hospital contributed "more than insignificantly" to her death.

Gladys Richards, 91, was taken to the Gosport War Memorial Hospital (GWMH) in August 1998 for recuperation following a hip operation after she had a fall.

She had a second fall and had to be transferred to another hospital for the hip to be manipulated back into place before she was returned to the GWMH.

She then suffered a haematoma, and Mrs Richards, of Lee-on-the-Solent, was given diamorphine administered through a syringe driver. She died four days later on August 21, 1998, the hearing was told.

Her daughters, Gillian Mackenzie and Lesley O'Brien, have campaigned for several years for a full inquest to be held into her death.

Mrs Mackenzie, 79, of Eastbourne, East Sussex, has questioned during the Portsmouth inquest whether the medical staff operated a policy of euthanasia and has accused the staff of "condemning" her mother to death through the palliative medication prescribed.

David Horsley, coroner for Portsmouth and South East Hampshire, ruled that the cause of death was bronchopneumonia.

In a narrative verdict, he added:

"Factors contributing more than insignificantly to her death due to bronchopneumonia were:

"Accidental falls which she sustained at Glen Heathers Nursing Home in Lee-on-the-Solent on the 29th July, 1998 and at Gosport War Memorial Hospital on August 13, 1998.

"Procedures undertaken at Haslar Hospital, Gosport to treat the injuries she suffered as a result of those falls.

"Her immobility subsequent to those procedures.

"Medication administered to her at Gosport War Memorial Hospital for the control of her pain and agitation.

"Her old age, frailty and end-stage dementia."

Mrs O'Brien, a qualified nurse, said after the hearing that she was disappointed by the coroner's verdict.

The seven-day inquest heard that Dr Jane Barton, who has previously been found guilty by the General Medical Council (GMC) of professional misconduct at GWMH, had prescribed levels of diamorphine for the nursing staff to administer in case Mrs Richards' condition deteriorated.

She also wrote on the patient notes that she was happy for the nursing staff to certify death.

But Dr Barton told the hearing that she "proactively prescribed" the medication because "the probability was her condition would deteriorate rather than improve".

But she said the higher levels of the prescription were only to be used in the situation that her condition did deteriorate.

She added: "She was in the end stage of dementia, she was likely to die in weeks or months from the dementia before the hip fracture intervened."

Dr Barton said that she believed that Mrs Richards' condition had deteriorated when she returned to the GWMH for the second time on August 17, requiring higher levels of painkillers.

She said: "I am saying when she arrived back on the 17th she was dying."

A previous inquest, specially authorised by then justice secretary Jack Straw, was held in 2009 into the deaths of 10 other patients at the same hospital all in the late 1990s.

The jury found that medication had contributed to the deaths of five patients and three of these had been given "unsuitable medication".

The GMC has also ruled that Dr Barton, who has since retired, was guilty of multiple instances of professional misconduct relating to 12 patients who died at the hospital.

The panel found a catalogue of failings in her treatment of the patients, who later died, including issuing drugs which were "excessive, inappropriate and potentially hazardous".

The failings included inadequate examinations of patients, failing to consult colleagues and poor note-keeping.

Hampshire police previously conducted a criminal investigation into the deaths of 92 elderly patients at GWMH but no prosecutions were brought.


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