Death brings raft of care changes

A RAFT of changes to palliative care for Oldham patients have been made after medical staff caring for a Failsworth man feared he had been given too much medication.

Nicholas Taylor (49), of Hibbert Crescent, Failsworth, was diagnosed with a tumour in his bowel in November, 2008 and later tumours in his liver.

He was being given morphine pain relief in tablet form at his sister’s Uppermill home and liquid omeprazole, normally used to treat acid reflux, up to his death on January 19, 2010.

However, an inquest at Oldham Magistrates Court yesterday revealed there was uncertainty among health professionals over the correct dosage given to him on the evening of January 18.

Mr Taylor’s sister Donna Howarth, now living in Holmfirth, told the inquest how she was concerned that her brother had been given too much medication at once, via tablets and a syringe driver, a battery operated device which delivers small doses of medication over hours.

She was also concerned as to why a note from a Macmillan nurse detailing pain relief for Mr Taylor was ignored by district nurses when they visited that evening.

Mrs Howarth said she was awoken four times in the early hours of January 19 by health professionals inquiring about the medication dosage, and that on-call doctor Sarmid Al-Kamil, who visited at 4am, said Mr Taylor had been given too much medication.

A post mortem examination revealed small tumour deposits in Mr Taylor’s lungs and liver failure.

Cause of death was given as disseminated carcinoma of the colon with morphine toxicity a contributory factor.

Oldham coroner Simon Nelson added that advanced liver failure was a contributory factor as well.

Julie Marie Evans, consultant forensic toxicologist, said the levels of medication Mr Taylor had received would not be toxic and it was highly questionable that the additional medication he received that day would have caused his death.

Simone Atkinson, a registered nurse who had joined Oldham Out of Hours service in January, 2009, treated Mr Taylor on the evening of January 18 with a colleague.

She said they had both individually calculated the dosage of his medication and concluded it would be safe.

With regards to the note from the Macmillan nurse, Mrs Atkinson said: “If I was shown the note, I wouldn’t have taken it into consideration because it was written on a piece of paper.“It would have to have been in the professional notes for me to act on it.”

Once back in the office, Mrs Atkinson said they discussed Mr Taylor’s medication levels with Sister Katherine Kearney, from the district nursing out of hours team, who agreed they were in the safe levels but thought it prudent to check.

After calling Springhill Hospice in Rochdale and the Go to Doc helpline, she said she contacted Mrs Howarth in the early hours to tell her to stop the syringe driver for safety reasons as the doctor at Go To Doc was unsure what to advise her and had wanted to consult colleagues.

Katherine McKenna, representing Oldham Primary Care Trust, which used to run district nursing in Oldham, and Pennine Care NHS Foundation Trust, which is now responsible for the service, said the trust’s own investigation had shown that the increased levels of morphine Mr Taylor had in the last 72 hours of his life were within accepted clinical practice for end-of-life care.

However, she said both trusts acknowledged that uncertainty around Mr Taylor’s medication had caused the family added distress during a very distressing time.

Beverley Melia, clinical services lead for palliative end-of-life care for Pennine Care Trust, said a series of measures had been implemented since Mr Taylor’s death.

These included:

A palliative care handover form, with updates on a patient’s condition and medication for out of hours nurses and doctors.

Syringe driver training.

Easy-to-read revised prescribing guidance with calculations for nurses.

Senior nurses to see complex palliative care patients.

Plans for a formal advice line on end-of-life care to Dr Kershaw’s Hospice to start in April.

Joint appointments between Go To Doc doctors and district nurses.

Mr Nelson gave a verdict of natural causes to which morphine toxicity precipitated by advanced liver failure was a contributory factor.

He said while he did not believe there were any failings on the part of the trust, there were matters in the care afforded to Mr Taylor.

He said the prevailing uncertainty because of lack of clarity of information at the time placed individuals in an extremely difficult position.

Speaking after the inquest, Mrs Howarth said: “It’s a great sadness that we as a family never got to say goodbye, so it is a good thing that other people won’t suffer like we did.”