STH Misuse of Drugs

Full explanatory details about what we eventually found out with the help of some NHS Doctors and Nurses, 4 years after the death of Thomas is below.

Sir Andrew Cash and the staff at STH - Sheffield Teaching Hospital Trust, responded to this succinte letter sent to them 9/2/10, written with the help of some honest NHS Staff, with just another whitewash, fobbing off letter! See Whitewash - Fob Letter category. N.B. Andrew Cash did offer to meet with us, the Family of Thomas. Please see 'Andrew Cash Questioned' & 'Poor practice Cover Up' to read what happened during the meeting 21/6/10!!!!

9th February, 2010

Dear Sir Andrew,

May I take this opportunity to thank you for the information that over the last 4 years you have slowly but surely released to me. I am however disappointed that you have failed to supply me with ALL the information that I have requested.

Notwithstanding the misleading and contradictory statements that the Sheffield Teaching Hospital Trust have made either in correspondence to me in the first instance or to my M.P. David Willetts or to the Press, I note that lately you Sir Andrew have written to Mr. Willetts (November 2009) to say:
“I can confirm that when the Healthcare Commission highlighted aspects of Mr. Milner's care which could have been improved, I apologised for these lapses and ensured that the recommendations were acted upon”.

I feel it is a great pity that this statement was not made to the Patients Association to be entered into their Report ‘Patients Not Numbers, People not statistics’ or to the various other Press Articles in connection with my Father’s case.

In those instances the Sheffield Teaching Hospital Trust said “a review had been carried out by the Trust and the Healthcare Commission about the medication given to Mr. Milner and it was found staff acted appropriately and professionally”.

I have now, with some friendly assistance from a group of Doctors and Nurses, reviewed the documents that have so far been provided.

No matter which way one looks at it, my Father’s morphine was tailed off when it should have been increasing.

I attach a graph that has been made in support of this statement. This chart has been made with the details as shown in the drug charts that have been supplied. See Appendix 1. For explanation to the attached Morphine Chart. (The Morphine Chart can be see under 'Our Evidence' catagory)

My Father suffered greatly as a result of this decline in the administration of morphine and he continued to suffer despite our requests that he be given adequate medication. At the end of life, sedation is the only way to alleviate psychological distress and anguish. Indeed it required our G.P.’s intervention to summon someone to help, a couple of hours before my Father died.

Disturbingly though, whilst we have been reviewing the notes, we could not fail to observe certain irregularities and anomalies, in particular in relation to the DDR/CD (Controlled Drugs) entries.

You must realise that you breached Patient Confidentiality and the Data Protection Act by supplying me with the unredacted DDR/CD. But this for our part only compounded exactly what did happen.

You must realise that myself and my Independent Witness saw the altered 20.20p.m. 10mgs amount for the 10/1/06 entry into the DDR/CD book when we viewed (26/1/10) the original’s of some of the documents in connection with my Father’s case. You unfortunately were trying to mislead David Willetts M.P. and myself that this had been a syringe driver, when in fact it was a 23.20p.m. 5mgs prn, as required, extra morphine subcutaneous injection, that had been administered.

You must realise that there is another clear discrepancy with the 11/1/06 8.45a.m. 2.5mgs amount recorded in the DDR/CD that does not match the corresponding 8.45a.m. 5mgs. amount recorded in the PRN chart. Disturbing though is ‘just what did happen to this vial of morphine’. We were there the whole time. Indeed I called the family G.P. at 8.30a.m. to summon help. Junior Dr. Morgan appeared on the ward at 9.00a.m. The 2 young nurses that I have repeatedly written about were ONLY in the doorway of the ward when at about 8.00a.m. they said ‘we cannot give him anything, you will have to wait until the Doctor’s do their rounds’. Dr. Morgan as you are aware wrote 9.00a.m. ‘Call from G.P. Daughter concerned. Tom pulling at the sheets’. If any amount of morphine had been given prior to Dr. Morgan’s arrival, I have been assured that my father, just 2 hours from death, would not have been displaying such tortuous movements.

Any alterations and non accounting for stock are contrary to not only the Trust’s own Policy but also the Law as this contravenes the ‘Misuse of Drugs Regulations 2001’ and the ‘Misuse of Drugs Act 1971’.
May I remind you of your own guidelines for 'Wastage/Spillage/Disposal of Controlled Drugs'. As you will know the correct procedure for the use of any amount of morphine that is less than the amount in the vial supplied, is to write ‘wasted’ at the side of the dose administered in the DDR/CD Book.

Unfortunately Mr. Richard Parker, Deputy Chief Nurse was misleading me and my Independent Witness when he said 26/1/10 that it was NOT the Trust’s policy to have to write ‘wasted’ in the DDR/CD Book.

The ‘wasted’ or spare amount should then be disposed of in a ‘Sharp’s Bin’. It is not used on other patients as Mr. Richard Parker, Deputy Chief Nurse informed me and my Independent Witness. Indeed it can be clearly seen in the unredacted DDR/CD chart, that you mistakenly disclosed to me, that no ‘spare’ morphine was used on other patients.

My Father suffered dreadful and unnecessary distress as he was dying due to failings on the part of the Sheffield Teaching Hospital Trust. See Attachments ‘Failings 7/1/06 – 11/1/06 and ‘Failings Post Mortem’ (Can be seen under 'Our Evidence' catagory)

There was enough information from the parental prescribing of morphine for the 7th January, (20mgs) and 8th January, (30mgs) to have allowed a better estimate of what needed to be in the syringe driver in the first place. 10mgs. of Morphine was too low a starting rate in the first instance but then to not provide Breakthrough Pain relief on my Father’s penultimate day, led the Healthcare Commission to conclude that the syringe driver was ‘low in the circumstances’.

There were NO clinical reasons for a decline in my Father’s terminal sedation. My father was NOT over sedated. Dr. Kay Stewart, Palliative Care Consultant wrote ‘not overdosed’ 10th January, 2006.
This obvious decline in the morphine administered to my father is why on the morning of the 11th January, 2006 he was presenting such tortuous movements ‘pulling at the bed sheets’ as Dr. Julia Morgan entered into the medical records, with tears coming down his face.

My Father was on a MacMillan Palliative Care Ward but it took the intervention of our family G.P. to get anything done.

I appreciate that 2006 is some time ago and no doubt the Trust hopefully has ‘Learnt some Lessons’ over this case.

It has occurred to me that these errors and failings in the care of my Father may have happened due to staff shortages and a shortage of qualified Palliative Care/End of Life Care staff.

Nonetheless these were serious shortcomings and it is only now right and proper that I should receive a full undertaking that this is the case. In the absence of that undertaking I will be put in a position where I will have to consider what, if any, further action I will be obliged to take.

Your actions 11/1/06 until now February, 2010 do not seem to mirror your STH Trust advertisement at www.patientopinion.org.uk “If we get something wrong, we will do our best to make amends'.

It is our policy that when mistakes are made we admit them and offer a full apology.”
May I take this time to say that I was never wanting anything but the truth about why Nurse Teresa Webster refused my Father his prn, extra morphine on his penultimate day. I feel that this Nurse failed in a professional capacity to help and care for my Father. However in my pursuit to understand why my father was allowed to be in a ‘pulling at the sheets’ state as he lay on a MacMillan Palliative Care Ward, 2 hours before dying, I discovered that his syringe driver was never titrated/gradually increased. Indeed by the morning of the 11th January, 2006 the syringe driver that had been refilled 22.50p.m. 10mgs 9th January, 2006, had actually run dry by 22.50 10th and indeed by the time I called the G.P. 8.30a.m. 11th January, it had been empty for 10 hours.

May I also take this time to reiterate that a no time was I or my family seeking financial compensation. It had been made clear to us a long time ago that due to my Father’s age and condition any compensation would be minimal. May I take this time to say again that I find monetary compensation to be obscene and having looked at the CNST ratings and other NHS Documentation am saddened that any detraction from the truth is based purely on finance.

The CNST (Clinical Negligence Scheme for Trusts) can be a guideline as to the standard of care that an NHS Trust is providing. We have been informed that the Sheffield Teaching Hospital Trust is only Level 1 and has had this rating for some time. This makes me question if ‘Lessons have been Learnt’ at least in the Trust’s provision of Palliative Care Services.

I kindly acknowledge the Patients Association Report in which my Father was Case No. 6, and hope that their highlighting failings in care in basic nursing may have gone someway to improve standards. Indeed Mike Richards, Cancer Tsar, has now said that training of staff caring for the dying must be mandatory.

I kindly acknowledge the Marie Curie Institute comments about how we had had an experience of a ‘bad death’.

I kindly acknowledge Ms. Christine Beasley, Chief Nurse and Government spokesperson’s apology for lack of appropriate care of my Father whilst at the Northern General Hospital, part of the STH Trust.

I am now unable to accept anything less than a full and unreserved apology for all of the failings that were made by the STH Palliative Care staff. These Healthcare workers were supposed to be caring for my Father and I feel that at this point, a full apology is the only decent thing to do. I respectfully ask that in order to mark that apology a Palliative Care Unit or Ward should bear the name of my Father. I would also suggest that any award made to trainee Palliative Care Nurses could also carry my Father’s name, as a timely reminder that at all costs dying patients should not have to leave this world in anguish.

Yours sincerely.