A Scary Medical Story Set In South Devon (And it's All True)

Vernon Coleman

My father was an inventor, company director and World War II naval veteran. He died on February 28th 2008. He was 87-years-old. The inquest into his death was held in Exeter. Although the inquest was held at my request I did not attend. This is the extraordinary, astonishing, almost unbelievable story of his death and of what followed.

On the morning of 5th February 2008, my father telephoned Dr Benjamin Hallmark at Budleigh Salterton Medical centre. My father was, according to Dr Hallmark, complaining of excruciating pain. But instead of visiting my father, Dr Hallmark simply told him to call 999.

I believe that if Dr Hallmark had visited my father then my father might have still been alive today. I'm old-fashioned and still believe that a GP has a duty to visit patients who call for help. (Even if an ambulance is also considered necessary.) If Dr Hallmark had visited he might have decided that my father did not need to go to hospital. And my father might still be alive today.

My father was taken to Royal Devon and Exeter Hospital where he was given extensive tests. No serious or new problems were found and the admitting consultant considered sending my father home again. He decided, however, to keep him in overnight. I know this because I was standing by my father's bedside at the time. My father was quite well. The pain was caused by a long-standing back problem. My father was sitting up in bed taking a very active interest in what was happening.

Unfortunately, the ward to which my father was sent had an outbreak of gastroenteritis. The ward was put in quarantine and no one could leave. My father caught the bug at least twice. He also contracted a chest infection and a urinary infection while in the Royal Devon and Exeter hospital. He naturally became weaker and frail. I rang him and the hospital staff several times a day and eventually managed to arrange for my father's release. Because two weeks in hospital (and a number of hospital infections) had made him too ill to go home I arranged for him to spend a week or so convalescing in the Cranford Nursing Home (close to his home in Exmouth). He went to the nursing home on 22nd February. The hospital had prescribed a regime to control his pain and given him an out-patient appointment for further investigations of his long-term respiratory problem. I was told that after admission to the nursing home my father was walking about and laughing and joking with the nurses.

On 25th February the nursing home staff called for my father's doctor. My father was again complaining of pain.

The doctor who called on Dr Hallmark's behalf, was a GP registrar, Dr Stuart Livingston. He prescribed Oramorph (morphine) for my father. The manufacturers of Oramorph state clearly that the drug should not be given to patients with severe respiratory problems.

Dr Livingston has stated in his report to the coroner, in support of his action, that he believes that the contraindication is `a relative rather than an absolute one'. The manufacturer of the drug, however, makes it clear that the contradiction is absolute. The company making Oramorph wrote to me on 16th June 2008 and told me: `...the use of Oramorph is contraindicated in any patients with respiratory depression or obstructive airways disease regardless of age.' My father had chronic obstructive pulmonary disease - a serious respiratory problem.

Dr Livingston suggested that prescribing Oramorph is acceptable in `end stage' respiratory disease. But my father was not `end stage' anything. I don't believe that Dr Livingston had ever met my father before he prescribed Oramorph for him.

I hadn't been able to visit my father for a couple of days (I had a bad cold and didn't want him to catch it) but I rang him regularly in the nursing home.

When I rang him on the morning of 27th February my father was having great difficulty in breathing. He also kept falling asleep. Suspecting that my father's drug regime had been changed I spoke to a nursing home employee called Martin and it was then that I discovered that my father had been given morphine (Oramorph). I was horrified. I have spent much of my professional life investigating the dangers of prescription drugs. I discussed the situation, and the person I spoke to (Martin) agreed with my opinion that if my father had another dose of the morphine it would kill him. I asked Martin to make sure my father was not given any more morphine and said I would take full responsibility for this.

I rang my father in the afternoon. The morphine had worn off and my father was much better. He was alert and not breathless. He was talking and breathing as well as he had been for some while. I said I would visit him the following morning. We discussed the morphine. I told him that I would take him some scientific papers showing that the drug was not safe for him to take. We were planning a trip to one of his favourite hotels to celebrate his birthday the following week. But at around 8 p.m. that evening someone at the nursing home gave my father another dose of Oramorph (morphine) as prescribed by Dr Livingston.

At about 8.15 p.m. to 8.30 p.m. a nurse rang me on my mobile phone to tell me that my father was a bad colour and was having difficulty in breathing. The nurse asked when I was visiting. I said I would be there the next day. I asked if I needed to visit immediately. (It would have taken me a couple of hours to get there). The nurse said she thought the next morning would be all right. She was wrong.

On my way to the nursing home the following day I was telephoned to say that my father had died.

I believe that my father would not have died if he had not been prescribed Oramorph by Dr Livingston. According to the manufacturer, the drug was clearly contraindicated. And my father, an elderly man, was especially vulnerable.

I also believe that if Dr Hallmark had visited, instead of simply telling my father to ring for an ambulance, my father might not have needed to be admitted either to the hospital or, as a result of the hospital admission, to the Cranford Nursing Home.

I decided that there was no point in attending Dr Earland's inquest because the coroner informed me that she had already decided (before the inquest) that Oramorph did not cause my father's death. She also decided not to have witnesses whom I considered vital at the inquest. (The two members of the nursing home staff to whom I had spoken about the Oramorph.)

As a registered GP and the author of numerous books on prescription drug toxicity, I firmly believe that my father's death was caused by Oramorph, and could have been avoided.

Prescription drugs are one of the top killers in Britain today. The wrong drug can kill a patient - particularly an elderly patient - as surely as a bullet. The medical profession as a whole still underestimates the problem - even though doctor-induced illness is now the third biggest killer in Britain. One in six patients in hospital is there because he or she has been made ill by a doctor.

I made a formal complaint to the General Medical Council about Dr Hallmark and Dr Livingston. To my dismay the GMC agreed with my father's GPs that any contradiction for the use of Oramorph in COPD patients is relative rather than absolute. They apparently ignored the fact that the drug company which makes Oramorph has an absolute ban on the use of the drug with COPD patients. The drug company stated that Oramorph is contraindicated in any patients with obstructive airways disease. I asked the GMC to explain why the defending GPs' views were considered more relevant than the manufacturer's advice. They refused to answer. And they refused to consider evidence from the professional witnesses who observed the effect the Oramorph had on my father.

If I was astonished by that judgement I was utterly dumbstruck by the GMC's decision that it is acceptable practice for GPs to advise patients living alone, and in excruciating chest pain, to call their own ambulance and then just wait for the ambulance to arrive.

That's medical care in Britain in the 21st century.

I think it stinks.

I don't know what my Dad thinks about it.

He's dead.

Copyright Vernon Coleman 2011