When Doctors Can Kill – And 'Get Away with Murder’
Dr Vernon Coleman MB ChB DSc FRSA
The patient was a World War II naval veteran and he was 87-years-old. This is the extraordinary, astonishing, almost unbelievable story of his death. It is a story with a message for everyone who has ever taken a prescription drug, been into a hospital or trusted a doctor. It is a story with a special message for anyone who can be classified as ‘elderly’.
The message is simple: beware. Especially if you are old.
At around 4 a.m. on the morning of 5th February 2008, the patient got up out of bed and made himself a drink. The pain in his back was terrible and he was having trouble breathing. It wasn't a new pain. He'd had it before. Knowing that if he rang too soon he would get the emergency medical service and probably be told to take two aspirin and ring his doctor in the morning, he waited until around 9 a.m. to telephone his doctor.
He knew that he needed to see the doctor but didn't feel up to driving to the surgery. It wasn't the first time he had the pain. He had a long-standing problem with his back: as the GP should have known he had chronic osteoporotic spine pain which caused pains all around his chest.
The patient telephoned his GP, Dr Benjamin Hallmark at Budleigh Salterton Medical centre. But instead of visiting his patient, Dr Hallmark simply told his patient to dial 999 and arrange for himself to be taken to hospital in an ambulance. The doctor couldn't even be bothered to make the telephone call to the ambulance station.
There is a good chance that if Dr Hallmark had visited the patient, then the patient might still be alive today – largely because he almost certainly would have not required hospitalisation. I'm old-fashioned and still believe that a GP has a duty to visit patients who call for help. Dr Hallmark clearly believes otherwise.
It was the first of many unfortunate decisions. And it was the beginning of a sequence of disastrous events which would lead to the patient’s death.
The patient was taken to Royal Devon and Exeter Hospital, which is Devon’s only teaching hospital, where he was given extensive tests. The doctors looking after him confirmed that there was no heart problem. The patient still had some pain and asked if he could have more morphine. The ambulance crew had given him some and he had, he said, rather liked the feeling.
The hospital consultant instantly said that he didn't need morphine and that it would neither be appropriate nor suitable.
The following day the patient asked the doctors if they could do anything about his breathing problems. More investigations were ordered.
But then the ward was infected with the Norwalk virus, a diarrhoea and vomiting bug which is named after a town in Ohio in the United States, and was closed. The patient was effectively imprisoned in the hospital. Because the ward was closed, there were no physiotherapists, no occupational therapists and no visitors.
In the next ten days or so the patient was, almost certainly as a result of poor hygiene in the hospital, twice infected with the Norwalk virus. The hospital staff did not seem to understand how such bugs are transmitted. The patient also contracted a chest infection and a urinary tract infection. (The latter developed after he was catheterised. He was catheterised because, like most 87-year-old men, he had been getting up at night to pass urine. Unfortunately, he got an infection and they had to take the catheter out. Anyone who gets a urinary infection from a simple catheterisation has been catheterised by a nincompoop.)
Eventually, after a flurry of calls on Friday 22nd February, relatives managed to arrange for the patient to be moved out of the hospital and into a nursing home.
The hospital hadn’t managed to do the tests which had been ordered because the ward had been closed.
By this time, after an enforced two week stay in bed, the patient was very weak. The pain which had taken him into hospital had long since disappeared. The patient was sent to the nursing home on 22nd February with his spare pyjamas in a bag. When the bag was opened, the pyjamas were thickly stained with diarrhoea remains. Perhaps not the best way to stop infections spreading.
The hospital had prescribed a simple regime to control the patient’s pain and had given him an out-patient appointment so that further investigations of his long-term respiratory problem could begin.
After admission to the Cranford nursing home in Exmouth, the patient was walking about and laughing and joking with the nurses.
On 25th February, Dr Hallmark was called to visit the patient.
The doctor who visited on Dr Hallmark's behalf was a GP registrar, Dr Stuart Livingston, who had never seen the patient before.
Dr Livingstone overruled the regime which had been carefully prepared by the hospital doctors who had looked after the patient. Instead, he prescribed Oramorph (a morphine product) as a painkiller.
This was yet another error.
The manufacturers of Oramorph state clearly that the drug should not be given to patients with severe respiratory problems. The drug is a version of morphine and it depresses respiration. The patient was 87-years-old and in old age drug effects can be dramatically enhanced.
Actually, to be precise the company making Oramorph says that ‘the use of Oramorph is contraindicated in any patients with respiratory depression or obstructive airways disease regardless of age.'
The doctor should have known that the patient had chronic obstructive pulmonary disease – a serious respiratory problem – and the patient should not have been given the drug.
On Wednesday morning (27th February) the patient was very drowsy, seemed drugged, and had difficulty in breathing. A medically qualified relative asked the nursing home not to give the patient any more of the morphine.
Sadly, the nursing home decided to ignore the request and gave the patient more Oramorph.
That was the last of a series of errors.
The result was immediate and the nurse who gave the final dose of the contraindicated noticed a sudden, dramatic change in the patient’s condition. Hours later the patient was dead.
There was an inquest into the patient’s death but for reasons which were never explained the local coroner, Dr Elizabeth Earland decided that the Oramorph did not cause the patient’s death and that she would not call the nursing staff who had witnessed what had happened to give evidence.
Moreover, she decided that the inquest would not be held in front of a jury although the rules say that an inquest should be held with a jury `if further deaths may occur in similar circumstances'. This was clearly the case.
`If he'd been a young child things might have been different,' said a policeman involved in the case. `The feeling is that the patient was old and had a long life.'
In the end, no one was disciplined. No one apologised. No lessons were learned.
The hospital claimed they did nothing wrong.
Two GPs claimed they did nothing wrong.
The nursing home said they did nothing wrong.
And the coroner said no one did anything wrong.
But the facts are that the patient was given a drug the manufacturer said he should not have been given. Within minutes his condition had deteriorated. He then recovered but was given another dose of the same drug. Within hours he was dead.
If it had all happened to a child, an asylum seeker or the wife of a cabinet minister, would the result have been the same?
Being over 80 clearly diminishes the significance of a death.
Will it all happen again? Yes, of course. No one seems to have learnt anything and no one thinks they did anything wrong.
No one has been disciplined.
Why should you care? Because you, or someone you care about, could be the next victim.
How do I know so much about this particular patient?
He was my father.
This wasn't a case of a patient being given the wrong dose of a drug. It was a case of a patient being given an entirely inappropriate drug.
No one has ever apologised, expressed remorse or regret or admitted they made a mistake. So, one has to assume, the same thing will happen again. And again. And again.
Prescribed drugs are one of the top killers in the world today. The wrong drug can kill a patient just as surely as a bullet.
How many other deaths are officially dismissed as natural causes?
How many deaths which should be investigated are never reported to the coroner? How many coroners refuse to investigate similar cases – or refuse to investigate thoroughly?
Why is it considered perfectly acceptable to kill patients through incompetence simply because they are old?
The lesson is: don’t trust doctors or hospitals.
Oh, and remember: iatrogenesis (doctor induced illness or death) is now as common as circulatory disease and cancer.
Isn’t that a surprise.
Copyright Vernon Coleman
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