THOMAS MILNER, a kind and gentle man, was 76 when he was diagnosed with myelodysplasia in June 2005. By October 2005 this had developed into leukaemia and he began weekly blood transfusions.
On 7 January 2006 he suffered a large gut haemorrhage and was losing blood from the rectum. He was admitted to A&E at Sheffield’s Northern General Hospital where he was given intravenous fluids. There was a “Do Not Resuscitate” notice in his medical records.
Once rehydrated, it was confirmed that Mr Milner was dying and he was given morphine on demand by injections, when his family noticed his distress. On 9 January, on the Medical Assessment Unit (MAU) a morphine syringe driver was set up and he was transferred to the Macmillan Palliative Care Unit (MPCU). This involved wheeling him 500 metres outside in the cold wearing only his pyjamas, to sit in a wheelchair for four hours while administrative forms were filled in. Once on the Macmillan unit he needed two extra morphine doses as he was very agitated, cold and frightened.
Heartbreaking and pitiful
On 10 January, staff on the unit started refusing to give morphine, writing that his family were giving him “dandelion and burdock” which “settled” him. For 15 hours on Thomas’s penultimate day he received no morphine and by the time night staff came on duty he was very agitated and lying in his own blood and urine (a scene his daughter describes as heartbreaking and pitiful).
The day staff failed to wash and toilet him, and failed to dress a huge sacral bedsore. By the morning of 11 January Thomas Milner was pulling at the bed sheets with tears rolling down his face. The family called staff and two junior nurses attended saying they could not give him anything and that the doctors would attend on their morning round. In desperation Thomas’s daughter called the family GP, who summoned a junior doctor who finally administered morphine at 9am. Thomas died at 10.40am.
A complaint was made to the Northern General and for the next six years the family sought answers from the hospital, the Nursing and Midwifery Council, the General Medical Council, the Healthcare and Care Quality commissions and the Healthcare Ombudsman. The answers became more absurd and contradictory as to why Thomas had suffered so much, why he was denied morphine and why his family had to resort to calling their GP for help. The NHS regulators took no action.
Thomas’s story was highlighted by the Patients Association in its 2009 Report Patients not numbers, People not statistics. Four years after Thomas’s death the family obtained copies of the controlled drug register and other drug charts that the hospital had originally said did not exist and found that they had been altered. His family believes that instead of logging the intervention of the GP and reporting a “significant untoward incident” on the day Thomas died, which would trigger an investigation, the matter was covered up.
The family alleges that the syringe driver was initially set up at the wrong rate in the assessment unit, and that the palliative care unit staff then failed to correct the mistake and did not refill it correctly or take into account the extra injections of morphine that had been needed. On Thomas’s last night staff failed to refill the morphine syringe driver at all. They also believe that unqualified staff had handled and administered morphine to Thomas, the details of which were later altered, perhaps to make it appear the syringe driver on his last night had been refilled
The hospital has confirmed that there was no Macmillan or palliative care nurse on duty on the two nights Thomas was at the palliative care unit, just very junior nurses. The trust apologised in 2010 for the lack of attendance to hygiene and the long wait in the wheelchair but not for the lack of pain relief. In March 2012 South Yorkshire Police began investigating whether any controlled drugs were unaccounted for, whether there had been deliberate cover up of failings in care following the complaint and whether there had been any genuine errors in record keeping. This investigation is still ongoing, and it is now more than eight years since Thomas Milner’s death. As with other NHS failings, the suffering may well have been prevented had enough specialist nurses been on the ward.