Incidents 50 and 53
3.22 Although there was nothing to suggest that the practices described in Incident 50 were generally followed, there was evidence that until' recently on Maple Ward the procedure was. to take away a new patient's possessions and clothes and put him in dressing gown order until he could be seen by the Consultant. Such a procedure was unnecessary and removed self respect. We hope that it no longer goes on anywhere, and we are sure that it would not have occurred if there had been a proper multidisciplinary approach to admission procedures, instead of leaving the Consultant with too much authority in matters which are not solely his concern. Drugs were sometimes prescribed by a doctor on the word of the Charge Nurse alone, but this was normally only done in an emergency or under great pressure of work. It is not a good practice.
Alleged excessive Medication
3.23 This will be a convenient point at which to consider the allegation made in Part I Of the critique that far too heavy a reliance was placed on chemotherapy. This is not easy to assess. Examination of random medication records does not reveal above average medication. Indeed, in some cases it is rather less than might have been expected. However, if this allegation is interpreted as meaning there was more chemotherapy on the long stay wards than would have been necessary if there had been a proper multidisciplinary approach to patient care, the charge has some substance, and is supported by the following matters:
(i) The evidence of Dr. R about the over—medication of Mr. T. He states that there were other instances of over-medication. (see paragraph 2.62).
(ii) One reliable witness spoke of a readiness to increase medication after an outburst by a violent patient, but a reluctance to reduce it again after a period of orderly behaviour. Two or three witnesses spoke of doctors renewing prescriptions without seeing the patient.
(iii) The treatment of Mr. LQ and Mr. GT in Heather had an emphasis on medication in place of a treatment programme. Indeed, where there are overcrowded and understaffed wards, particularly those containing disturbed patients, there may often be greater reliance on medication than if the same patients were cared for in smaller groups with a higher staff ratio. Shortage of occupational and industrial therapy on the wards will tend to increase the need for medication still further.
(iv) Examination of medicine cards on long stay wards suggested that many patients went for long periods without medication review. For example, out of 30 cards selected at random on Hawthorn ward in September, 1975, half showed no review within ten months, and of these 12 had not been reviewed for 12 months. It could be argued that all these patients were stabilised on medication and that no change was necessary, but since many of them were old and frail it seemed unlikely that no change could have occurred from one year to the next. It could also be argued that every time a doctor visits a ward and has a discussion with nurses an automatic review of the medication takes place, since problems should be drawn to his attention, and he can reasonably assume that there is no need for change if no problem is presented. This in our view overlooks the fact that many patients, particularly the elderly, are notorious for failing to complain of symptoms, and that those living with them from day to day, whether relatives or hospital staff, may not notice the insidious and subtle changes which herald serious, and sometimes treatable, disease.
Incident 54
3.24 Examination of random case notes revealed that this was very often true on long stay wards. An improvement was noticeable during 1974. Incident 56
3.25 The first sentence is substantially true of the long stay wards.
Incident 60
3.26 The ward referred to is Ebony, and the allegation, which we find proved, relates to an examination of the case notes by a social worker in mid-1974. Random examination of other case notes in other long/stay wards revealed that until the first part of the Critique was circulated it was common for no entries to be made for periods of 12-18 months, and on occasions there would be gaps of over two years.
We recommend that:
3.27 1. The medical, nursing and pharmacy staff should review the concentration and content of all syrups where more than one strength is available to see if simplification would reduce the risk of accidents and overdosage. They should also review the use of various beakers and measures. 2. The Nursing Officers should agree with ward charge nurses and sisters a regular programme of monitoring and supervision of all less trained nursing staff (including those with long service) who are involved in giving medication of any kind. 3. The medical staff should agree a minimum frequency With which patients' progress and medication is reviewed. 4. The medical staff should agree a system of monitoring to see that the policy for patient review is implemented and any failing reported back to the Medical Staff Committee.
09 February 2025
