Friday 28 October 2011

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.

Thursday 27 October 2011

Liverpool Care Pathway – A DNR Directive For Paramedics And First Aiders

Paramedics will be told of a patient's end-of-life wishes, under Department of Health plans to extend the use of electronic medical records.


First Aiders train to become First Aiders to make a difference. With first aid knowledge you can be the difference between life and death.


The most life-threatening condition a first aider may be called to deal with is a casualty that is not breathing.

If a person does not respond to the sound of your voice or to gentle pressure applied to their body, it is likely they are unconscious.

You should then check for a response. Gently shake their shoulders.

Check breathing. If they are not breathing commence cardiopulmonary resuscitation ( CPR). Cardiopulmonary resuscitation (CPR) is a technique whereby oxygen is pumped around the body using a combination of chest compressions and rescue breaths.

WAIT! Check first to see if there is a living will directive to DNR!


The Mail Online reports:

Do Not Resuscitate: Paramedics to get access to patients' end-of-life wishes



 CLAIRE BATES writes -

Paramedics will be told of a patient's end-of-life wishes, under Department of Health plans to extend the use of electronic medical records.

It comes a year after a ministerial review into Summary Care Records, which are being drawn up for every patient in England unless they have 'opted out' using a special form.

The computer database has been set up to give GPs, hospital doctors and paramedics immediate information about patients, such as allergies and medications they are taking.

However, now patients with serious illnesses are being encouraged to add extra information about their conditions in consultation with a GP to make it easier for doctors and nurses to treat them in an emergency.

This could include whether they want to be resuscitated and if they wish to die at home.


The scheme is backed by a number of charities as well as Health Minister Simon Burns, who said: 'Some seriously ill patients have added information about their end of life wishes to their record, helping to ensure that their wishes, typically to die at home, are respected.

'This is because information about their wishes can be shared with everyone including, most critically, out-of-hours doctors and paramedics, involved in their care.

He added that some patients had added 'do not resuscitate' requests to their records, which had saved them and their loved ones 'needless distress.'

'This is hugely encouraging, offering the prospect of making sure that many more patients' wishes for a dignified death at home are honoured,' he told the Daily Telegraph.

WHO CAN ACCESS MY SUMMARY CARE RECORD?

According to the NHS, people who can see your records...
Need to be involved with your care
Need to have an NHS Smartcard with a chip and passcode 
Should only look at the information they need to do their job
Should have their details recorded – who they are and if they have added or changed information

However, they admit there is always a small risk when information is held on computers, that confidentiality could be breached.

Patients can only opt-out of the system if they fill in a form when informed their record is being drawn up. You can ask to have it deleted later on but this may not always be possible.

Jim Petter, Director of Professional Standards at the College of Paramedics, told Mail Online that any improvements to the current situation would be welcome.

'At the moment very ill patients can have a Do Not Resuscitate order,' he said.

'But these can vary from a handwritten note to a legal document from a solicitor. 
'Paramedics are often entering a very intense situation and have to balance trying to verify the document with the need to start treatment quickly if the evidence doesn’t stack up. 

'This decision often needs to be made in minutes and you can often have upset relatives with their own opinions too.

'At the moment in the absence of firm written evidence that the patient does not wish to be resuscitated we would go ahead and treat them.

'Anything that could standardise and verify a person’s end-of-life wishes is laudable.'
However he was wary about how such a complex national system could be implemented.

'The processes and systems would need to be very well-defined,' he said.

'We would need to see evidence in the record of a patient's discussion with their GP about their decision not to be resuscitated - preferably on a headed document and with the GP’s contact details.

'It's not clear how paramedics would get access to the Summary Care Records as we cannot see them on the ambulance computer at the moment.

‘I would also want to know who would be responsible for keeping the record accurate and up to date?

'At the moment I feel a print out kept with the patient would be the safest option. I can imagine a situation where there are two patients with the same name at a nursing home. Mistakes can be made.’

Meanwhile a number of charities have backed the move to allow patients to add extra information to their records. One example is that patients with asthma would no longer need to repeat their medical history while struggling to breathe.

Neil Churchill, Chief Executive Officer of Asthma UK, said: 'Summary care records are a vital step forward in delivering safe and effective patient care.'

A spokesman for the Muscular Dystrophy Campaign said they knew about incidences where a patient's health had suffered because doctors were unfamiliar with the rare condition. One patient who had entered hospital able to walk was left wheelchair-bound because of inappropriate care.

Nic Bungay, Director of Campaigns for the charity, said: 'We see the great potential for Summary Care Records to support staff across the NHS in dealing with rare conditions.

'We encourage patients to take ownership over the records.'


To make Advance Directives available to all medical operatives including paramedics - who would only be involved in an emergency call situation in any case - is both precarious and hazardous such that it borders on folly. If there is injury which will result in certain brain incapacity… should the paramedic then determine to proceed with a DNR directive? Is the extent of any resultant brain incapacity determinable in the situation? Delay will certainly compound any risk but will the paramedic, in the knowledge of the DNR directive on file, still risk resuscitation knowing that prosecution may result if this is disobeyed?


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 desirable alternative option.

Liverpool Care Pathway – A Dialogue Of Correspondence





A Dialogue Of Correspondence


 We were advised by both the Parliamentary and Health Service Ombudsman Service and the Healthcare Commission that they are unable to achieve disciplinary action against individual members of staff. They recommended that we take our complaint to the NMC if we wished to pursue that outcome.

The NMC had this case for over a year during which time the Trust withheld documents for nearly three months, dragging their feet while they were sanitised, perhaps.
Here:
Dear Leslie,

My attempts to have this in a position to pass on have been somewhat thwarted by NHS Surrey's delays in getting the required documentation together.

I wrote to them in February, initially requesting a response by 1 March, although I have been asked for three further extensions to this, which I have granted. Their final extension was w/c 29 March, so I hope that as I have accommodated their requests, they will abide by this date and send in the documentation this week.

I will update you as soon as I hear anything.

Regards,
Viz Bhuwanee
Case Officer
Fitness to Practise Directorate
020 7462 8873 (direct)
020 7462 5800/5801 (switchboard)
020 7242 9579 (fax)

Nursing & Midwifery Council
Fitness to Practise Department
Centrium
61 Aldwych
London, WC2B 4AE

Dear Leslie,

I have chased them up today and left a message.

I last spoke to them at the end of March, and they stated they had a problem copying the documentation, although I expected a response by now. I shall contact our legal team unless the information requested is not sent through by Monday.

Regards,
Viz Bhuwanee
Case Officer
Fitness to Practise Directorate
020 7462 8873 (direct)
020 7462 5800/5801 (switchboard)
020 7242 9579 (fax)
Nursing & Midwifery Council
Fitness to Practise Department
61 Aldwych
London, WC2B 4AE

That same day, following Mr Bhuwanee's threat to proceed via their legal team…


Dear Leslie,

I have received notification that a bundle of papers has been delivered to our offices regarding this case today.

I should be in a position to move this case on in the next week.

I hope this helps.

Regards,

Viz Bhuwanee
Case Officer
Fitness to Practise Directorate
020 7462 8873 (direct)
020 7462 5800/5801 (switchboard)
020 7242 9579 (fax)

Nursing & Midwifery Council
Fitness to Practise Department
61 Aldwych
London, WC2B 4AE

We first wrote to the NMC on 12th November 2009. They eventually wrote back on 12th January 2010. The Case Officer, Mr. Bhuwanee, first contacted us on 26th January 2010.


Mr Bhuwanee spent some time trying to get all the papers he needed from the Trust and actually confided in one email that, if they did not respond, he would contact their legal team.

Mr. Bhuwanee contacted us by email on 11th May 2010 to inform us that we should hear from the investigating committee in 2 to 3 weeks.

Mr. Bhuwanee then observed ‘radio silence’ for a period. A succession of emails and letters received no response.

Dear Sir/Madam,

RE: Mrs Grace Doe

We first wrote to you on 12th November 2009. You eventually wrote back on 12th January 2010. Mr Bhuwanee’s first contact with us was on 26th January 2010.

Mr Bhuwanee spent some time trying to get all the papers he needed from the Trust and actually confided in one email that, if they did not respond, he would have to consult your solicitors.

Mr Bhuwanee contacted us by email on 11th May 2010 to inform us that we should hear from the investigating committee in 2 to 3 weeks. We have since learned, via a telephone conversation with your office, that Mr Bhuwanee has left. As at this date, the 23rd July 2010, we have heard nothing at all from the Investigating Committee.

We visit my mother's grave throughout the year, but yesterday, the 22nd July, was three years to the day this dear lady was taken from us. The whole family went to pay our respects, to celebrate her life and to mourn her death at the hands of staff at Caterham Dene.

There is much explaining to do. This lady was sharp and attentive, as the two Specialist Nurses, Heidi (and her daughter, present on work experience) and Diane, will testify. In Caterham Dene, they took her off all ongoing medication, broke her hearing aid and reduced her to a condition of utter senselessness. She was stuffed so full of morphine that she couldn't talk or think and died of heart failure. 

I must clarify that my mother did not leave this world at Caterham Dene. They waited until the point was reached that death was inevitable and only then decided to telephone Thamesdoc before phoning for an ambulance one hour later. At least, whatever may be in the written record, an hour elapsed between the two telephone calls they made to me and I actually arrived at ESH a&e before the ambulance, and was present when they brought her in already dead.

The nurses at Caterham Dene had been permitted to administer the prescribed dose of morphine as they thought fit. The Trust had to require Caterham Dene, on the Commission's recommendation, to change this lax state of affairs. Whatever may be in the written record as to what was administered, that should be looked at in the context of the Commission's report as regards errors in the written record.

This should also be looked at in the context of what the Sister asked us upon our arrival at Caterham Dene. Do we, in the event of anything happening - not that it would - want them to move her to ESH? What a peculiar question to ask. It makes no sense except in the context of a policy being set in place at Caterham Dene to let them go and actually help them on their way!

Can we be informed, please, how this matter is proceeding?

Yours sincerely,

We then learned, via a telephone conversation with the NMC office, that Mr Bhuwanee had left. As at the 23rd July 2010, we had heard nothing at all from the Investigating Committee.

The replacement Case Officer, Mr. Tilling, maintained that there were only three named registrants and that the NMC may proceed against only named registrants. However, these three registrants were not those at Caterham Dene; they were from the District Nurses Office. In their dalliance and feet-dragging, had the Trust 'sanitised' the record of all other names?

Mr. Tilling had been consulting with his managers upon precisely this matter. He stated:

I have had a discussion about this case with my manager, and it appears that no other nurses can be idenitfied except for the three in the subject heading. The Triage team, with whom you were in previous contact, opened the file in this way for this reason.

Mr. Tilling then observed ‘radio silence’ for a period. Our persistence produced a response, eventually, from his manager, Mr. Brindley.

Mr. Brindley informed us with much aplomb that Amirius Tilling had now left the NMC, as though we were seeking some scapegoat to satisfy our complaint and that he had found one. What is more, quite the magician, he pulled a further 12 NMC PINs out of the hat and presented them to us in the manner of a magician’s parlour trick! He did not supply us with the detail but only the knowledge, so we had no information of their identities, but where had they sprung from if Mr. Tilling had claimed that no other nurses could be identified…?

When Mr. Tilling had made this claim, did he mean there were no other nurses who could be identified or that those additionally identified were not considered as relating to the case? Was this the problem that Mr. Tilling had and was that why he was consulting with his managers? Had Mr. Tilling been wronged? Was he owed a most profound apology? Was he being honest in the face of what was plainly institutional DIS-honesty?

Mr. Brindley said, with much aplomb, Amirius Tilling had now left the NMC - as though we were seeking some scapegoat and that he had found one. First, Mr. Bhuwanee, then Mr. Tilling, - but did they jump or were they pushed? Was the NMC simply playing out a ruse to hoodwink us that all was proceeding well? It is almost as if the NMC exists not to root out the bad crop but, rather, to bury the rotten apples at the bottom of the barrel.

Our experience of this interminable maze of a complaints process is that there is a system in place that sets out to cover the tracks of the wrongdoer at every twist and turn. It is no wonder to us at all that there are people like Shipman who can, quite literally, get away with murder.

So, what was all this time-wasting for? There had to be a reason. It could not be, surely, that a professional body such as the NMC could be so utterly incompetent as it has made itself appear to be? Could it possibly have been to take the complaint beyond the three-year cut-off point for legal action to proceed? They need not have been concerned. The fact is that this dear lady's life was not worth a jot in any case.

When it became clear that we could not obtain justice through the complaints process, we actually approached a number of solicitors. We were told, quite plainly and simply, that it was all about money. Loss of future earnings was zilch and mum had no dependents. The three days of suffering at the hands of the registrants at Caterham Dene was but a trifle and all she was worth was the cost of her funeral expenses. The case was just not financially viable enough to proceed with. It was a cruel honesty for which the solicitor apologised. Well, she was honest with us, at least.

In context with our reference to Shipman above, the solicitor confided to us during the telephone interview that our experience is not uncommon in the NHS and a culture has developed of nurses taking it upon themselves to determine quality of life and putting people down like pets at a veterinary surgery! She made these comments in response to my account of what occurred at Caterham Dene.

We placed this case before the NMC to obtain justice for my mother. We were assured that, through the offices of the NMC, we could obtain something approaching the reprimand at very least that we expected for these miscreants. Recommending 'learnings' was an insult to her memory! This dear lady perished in a place which, in her own last words to me before they turned her into a virtual vegetable, she found objectionable. She actually said she ‘didn’t like them in there’. The Trust played us a merry dance for long enough and the NMC did the same. Is the NMC just another beast without any teeth?

Responding on behalf of Professor Dickon Weir-Hughes, Chief Executive and Registrar, Mr. Peter Pinto de Sa stated:

We are not empowered to undertake a general investigation into the performance or conduct of unnamed individuals at a particular institution or organisation where it is said that there have been general failings on the part of that institution or organisation or its staff in general.

In other words, the registrants at Caterham Dene were following policy and could not, therefore, be held personally responsible. They had followed procedure!

Nevertheless, the NMC forced three innocent nurses to suffer such scrutiny by the IC and pursued the case over the Christmas period – the worst of all possible times for them – for anyone! Those rascals at Caterham Dene Hospital in the meantime were permitted to escape into the woodwork because, as we now understand, they had adhered to the hospital procedure and the protocols of the Liverpool Care Pathway.

Further correspondence followed:


























Euphemism will not conceal the plain and simple truth that it is the intention of the Liverpool Care Pathway, by omission and by commission, to take a life. 

Take note, therefore: The NMC is here advising all those who feel their friend or kin were placed on the LCP wrongfully and did, thereby, have their lives taken should contact the police!


Dear Ms. Whitfield,

With respect, you cannot appreciate or understand the extent to which my mother’s untimely death still affects this family. It is now almost four years since this lady was taken from us and the more we have discovered through this time has served only the more to distress us further, that these are the awful times in which we live and that the nursing profession has sunk to such a dismal level. The disgraceful things we read almost on a daily basis in the newspapers serve only to confirm what we have discovered for ourselves. And the NMC, which should be gainfully employed in pursuing a gold standard of conduct in the nursing profession, averts its gaze and does nothing.

This lady, my mother, a grandmother and friend, a lady who had attained the age of respect - a respect which she did not receive at Caterham Dene Hospital – suffered indignity to her person and damage to her property, a hearing aid, without which she could not possibly have knowingly communicated any such consent as your registrants claim to have done, to being dosed with the morphine which reduced her to the condition in which I found her, that of a virtual vegetable. Her last words to me in this world haunt me to this day, that she didn’t like them in there! How in heaven’s name can Dickon Weir-Hughes step in, remove this case from the scrutiny of the IC and deny that there is any case to answer? How may he? How dare he!  It doesn’t make sense. An explanation really is warranted!

The NMC forced three innocent nurses to suffer such scrutiny by the IC over the Christmas period – the worst of all possible times – and these rascals at Caterham Dene Hospital are permitted to escape into the woodwork. The only sense that we can make of this is in the context of a statement made to us by Mr. Peter Pinto de Sa:

We are not empowered to undertake a general investigation into the performance or conduct of unnamed individuals at a particular institution or organisation where it is said that there have been general failings on the part of that institution or organisation or its staff in general.

Are all these reported failings at Caterham Dene Hospital, such as permitting mum to present cyanosed and doing nothing, only apparent failings and actually a result of adherence to and pursuance of the Liverpool Care Pathway? You state that there is nothing more to be said but explanation really is required! It does not make sense. You state that you do not consider that any new material has been supplied. Perhaps, from the standpoint of the NMC that is so but, from our standpoint, that is certainly not the case.

In previous correspondence with the PCT, the HC, the PHSO, and the NMC, we have continued to state our belief that there is no other explanation for my mother's sudden and rapid decline and demise at the hands of persons unknown at Caterham Dene than that this was by a tacit policy to 'let them go' and to actually 'help them on their way.' We have supplied good reasons to support this belief. We have expressed this belief since July 2007, right up unto the present time. This belief has never been denied; rather, it has just been passed over without comment or mention. Only now have we discovered, and to our utter dismay, that the flawed Liverpool Care Pathway was and is in use at Caterham Dene Hospital.

It has taken almost four years to confirm our belief to be true and that is an utter disgrace. What is distressing and worrying is that no-one - until now - thought to speak up and comment upon the incidents we have reported to have occurred, to recognise in them the implementation of the Pathway, and to assure us that this was not at all some tacit policy as we had suggested but a perfectly open and above-board set of procedures and guidelines being rolled out across the NHS. It does not make sense.

So, why the reticence? Is the belief of Dr. Peter Hargreaves, Consultant in Palliative Medicine, and others that this protocol is both flawed and dangerous more widely held? Are there many more that do hold this belief but prefer, for professional reasons, to remain silent? It does not make sense.

In previous correspondence with the PCT, the HC, the PHSO, and the NMC, we have continued to assert that mum was robbed of her life, that her life was taken. This assertion has never been denied; rather, it has just been passed over without comment or mention. Only now is it suggested that this actually be referred to the police! This is only what does occur under the Liverpool Care Pathway, after all: lives are taken. Should this protocol actually be a matter for police referral, then?

It is these circumstances of our loss that move us to pursue this cause with such vigour, as you may surely understand from our accounts of the matter related to you in the ‘copious’ correspondence! Indeed, it is not for ourselves and our loss that we fight on but for my mother and because of the circumstances of her death – the manner in which she was actually robbed of her life! We may not come to terms with our loss whilst this injustice continues.

In pursuit of this cause over the past almost four years, we have been ignored, lied to, and our petitions have actually been returned ‘refused’ by Royal Mail! The HC report readily owns up to actual falsification of the documented record and provides a litany of failures. Are these all to be excused as no matter worthy of mention? Why, yes, for you are not, in the words of Mr. Peter Pinto de Sa, ‘empowered to undertake a general investigation into the performance or conduct of unnamed individuals at a particular institution or organisation where it is said that there have been general failings on the part of that institution or organisation or its staff in general.’

You end your letter with the bitter and sarcastic note that you would normally provide details of further organisations to which we could refer our concerns. Does the NMC and do those that hold office under its aegis know no end of shame and, in this case, ignorance? Given Mr. Peter Pinto de Sa’s statement in the regard of ‘general failings on the part of that institution or organisation or its staff in general,’ we might pursue this matter further with the Care Quality Commission.

Will the NMC, if it will do nothing more, not add its voice to that Dr. Peter Hargreaves and others and raise a hue and cry to get this Care Pathway rolled back and removed? The Liverpool Care Pathway was a tool designed to be used with patients already diagnosed to be terminally ill; it was never a diagnostic tool per se to determine a terminal condition. It was designed at the Marie Curie Hospice in Liverpool specifically for the terminally diagnosed patient and to recognise when a point had been reached that death was near or imminent so as to provide as peaceful and gentle path from this world as might be provided. These patients were already diagnosed to be dying from cancer; the Pathway was not the tool used to make that diagnosis, but a means - a 'pathway' to follow - to determine that point.

Clearly, anyone who falls into the clutches of the proponents of LCP and ticks all the boxes will be given assisted passage into the next world care of the NHS. This will apply particularly to the elderly who are, in any case, already suffering from that most terminal of all conditions - Old-Age! This will apply even contrary to the expressed wishes of patient and family, as this family has discovered at Caterham Dene. This also explains the belligerence of the nurse at our protests, that it was I who was being 'uncaring' not she. Of course! Now, her attitude makes sense.

A culture of death is pervading the NHS. A dark shadow is stalking our hospitals and care homes. The right to death is becoming paramount over the right to life. The LCP is providing a newfound legitimacy and cover to an unspoken policy that has, actually, been in place for decades!

A proper response is demanded and expected.

Yours sincerely,