Lois Rogers

Journalist and Communicator

Cheap, faulty and pumping death straight into the veins

Health

In a police interview room in the market town of Fareham, near Portsmouth, two detective constables sat opposite Dr Jane Barton and turned on the tape. The date was April 6, 2006. Operation Rochester had begun. Barton had faced questions about her behaviour for years. Why did she prescribe toxic painkillers when her patients were not in pain? Why did she act in a “brusque and know-it-all way” when relatives asked why their loved ones had suddenly died?

Yet she had never been questioned like this.

“Doctor, will you please give your full name and your date of birth?” “Jane Ann Barton,” she replied. “19th October 1948.” A red light flashed on, indicating another detective was listening in on the interview from outside.

Over the next hour the detectives interrogated Barton about a string of suspicious deaths that had occurred under her watch at Gosport War Memorial Hospital in the 1990s.

Specifically they asked questions about her use of Graseby syringe drivers — battery-operated pumps — a line of inquiry in the investigation that had been hidden until today’s revelations in The Sunday Times. Apart from her name and date of birth, she volunteered nothing. Detailed questions were met with “No comment”.

Barton’s refusal to participate — and a supposed lack of evidence elsewhere — would result in the police investigation crumbling within weeks, setting back the families’ desperate search for answers by more than a decade.

Last week a government panel finally ruled that the woman known as “Dr Opiate” was responsible for causing the deaths of up to 650 patients. She did this by prescribing diamorphine, also known as heroin, with no medical justification and for patients who were in no apparent pain in 55% of cases.

But how did Barton, now thought to be at her holiday home on Menorca, Spain, administer so many fatal doses?

Our investigation reveals a much wider scandal involving the use of dangerous syringe drivers in NHS hospitals across England and Wales, which may have led to the deaths of thousands of vulnerable patients.

Today a whistleblower has accused the panel of creating a “cover-up within a cover-up” by ignoring “awkward questions” about how Barton and her colleagues compounded the lethal risks to patients in their care by the use of these cheap and faulty devices. In explosive claims, supported by a leaked cache of documents, the whistleblower says the government panel passed over evidence that asked questions not only about Gosport hospital, but about institutional failings across the NHS. It is the “cock-up or conspiracy” culture that the panel itself says protected Barton.

The accusations centre on the flawed Graseby MS 16A and MS 26 syringe drivers that were in use at Gosport and across the NHS at the time. The plastic devices were loaded with syringes and programmed to release drugs into a patient’s bloodstream over a sustained period of time, removing the need for manual injections. They were designed to free up doctors’ time. According to documents seen by The Sunday Times, the syringe drivers became Barton’s instrument of choice in prescribing drugs at Gosport during the 1990s.

An elderly patient would be hooked up to the devices and drip-fed diamorphine for hours at a time. The opiate injections would continue until patients’ lungs failed and they suffocated. It meant patients who arrived at Gosport hospital expecting to make a full recovery would leave in body bags.

What the report does not mention is that Graseby syringe drivers were notoriously dangerous — and not only in the hands of rogue medical professionals.

By 1995, the British medicine regulator had declared the drivers unsafe and non-compliant with modern standards, admitting that they caused deaths. The following year NHS inspectors reached similarly striking conclusions and found the drivers had led to “severe over-infusion and fatality”, issuing a hazard warning on the product.

In the worst cases, the syringe drivers were found to randomly dispense “incorrect” doses of drugs, leading to unexplained deaths. But the most common problem was far more prosaic. MS 16A and MS 26 drivers looked almost identical, yet they released drugs into the bloodstream at different rates — the former in an hour, the latter over 24 hours — meaning distracted and poorly trained doctors and nurses could easily mix up the two and accidentally administer fatal overdoses in an hour.

As the NHS mulled over whether to recall the devices, doctors were left to deploy makeshift solutions. “I worry about confusion between MS 16A and MS 26,” confessed one GP in an anonymous testimony, before explaining his quick fix: “Aluminium foil labels.” For a limited time Graseby offered hospitals fluorescent stickers at a “special rate” of £1 to highlight which syringe driver was which, but confusion persisted.

The devices, launched in the mid-1970s, were not designed for modern medicine. A booster button could be pressed and used to inject the contents of the syringe at once, but there was no “stop” button. The infusion rate could be fiddled with mid-session, but there was no alarm. A screwdriver was needed to adjust the dose, which was — bizarrely — measured in millimetres, rather than the industry standard of millilitres.

“In the aeronautical industry you would never have mixing of units and near-identical devices, it would obviously lead to errors. These devices were responsible for human life — it’s astonishing so little care was taken,” said one expert.

Crucially, these flaws meant that Graseby syringe drivers were vulnerable both to human error and to tampering by rogue clinicians.

Rob George, professor of palliative care at King’s College London, said the idea that doctors and nurses used the MS 16A and the MS 26 on the same ward was the most “scary” practice. “Most organisations would never mix the 24-hour one and the one-hour one on the same unit,” he said.

But Gosport was one of the hospitals where this took place. Both syringe drivers were used during Barton’s tenure — making her conduct more dangerous. They were also used after her departure, which could help explain why a number of suspicious deaths took place at Gosport while she was on holiday and after she had left the hospital in April 2000.

Documents identified by The Sunday Times reveal the severity of the problem. In August 2001, more than a year after Barton left the hospital, a risk management group found the Graseby syringe drivers had led to a series of “critical incidents”. The same year, 108 syringe drivers were withdrawn from the trust.

A 2001 incident report describes confusion and a lack of training among staff when it came to using the devices. “Doctor prescribed a diamorphine syringe driver, which both staff nurses were unable to give,” it reads. “Staff nurses phone all wards to get help as patient distressed. No one willing to help.”

Police detectives themselves understood the peril of the syringe drivers. During their interviews with Barton at Fareham police station as part of Operation Rochester, detectives repeatedly probed her on the differences between Graseby MS 16As and MS 26s.

“What are the differences between these syringe drivers?” “What is the difference between the MS 16A and the MS26?” “Has one got a boost facility?” “What colour was the syringe driver used?”

To every question, Barton responded: “No comment.”

However, one of her colleagues did talk. The consultant geriatrician on Barton’s ward, Dr Richard Ian Reid, told police that he could not remember which device was which, and that they were “totally confusing” and “really dangerous”. Reid explained how Portsmouth healthcare had stopped supplying one of the drivers in order to avoid serious mistakes.

Yet none of this is mentioned in the Gosport report. There was no questioning about why dangerous equipment was used at the hospital, nor discussion as to whether Barton knowingly manipulated the drivers to increase opioid injections. Nor is there any reference to incidents linked to the Graseby syringe drivers after Barton’s departure.

A police investigation into suspicious death caused by diamorphine overdoses at Gosport in 2003 — three years after Barton had left the hospital — does not appear anywhere in the report.

Operation Liffin was the code name for the inquiry launched by Hampshire police after they were called on to investigate the suspicious death of an 84-year-old man. He had died on October 22, 2003, after “accidentally being overprescribed an administration of diamorphine”, according to police papers from the time.

Despite the extraordinary similarities to the deaths that had occurred under Barton’s watch, however, the issue of the syringe drivers was dismissed in 39 words by the panel: “The panel has considered issues concerned with the particular syringe drivers, known by their trade name of Graseby, and is aware of the hazard notices which applied. The panel’s analysis does not rest upon any issue relating to these notices.”

According to the whistleblower, the syringe issue was “buried” because of its implications for the NHS as a whole.

The Sunday Times has discovered that Graseby devices have been linked with overdose-related deaths in other parts of the UK over the past 15 years, including Wales, South Yorkshire, North Yorkshire, Derbyshire, Devon, Cornwall and the Isles of Scilly. Graseby-linked deaths continued to occur in the NHS until at least 2013.

The panel was allegedly warned that if the issue were allowed to emerge, it would require the establishment of a Department of Health national helpline, the setting up of a no-fault compensation fund and a year’s work of legal and financial preparation.

The source claims the panel was reluctant to go down that path. The whistleblower, a senior Department of Health official, said: “Anyone who has lost their granny over the last 30 years when opiates were administered by this commonly used syringe driver will be asking themselves, ‘Is that what killed Granny?’”

Any thorough examination of the syringes issue would have posed serious and uncomfortable questions of the health service. Deaths caused by Graseby syringe drivers were raised in the NHS as early as 1995. Yet nothing happened.

Over the coming years, other countries forced the devices out of circulation. In 2007 New Zealand’s health regulator held meetings with Graseby’s owners, the £6.84bn conglomerate Smiths Group, and persuaded it to voluntarily withdraw its devices from the market.

In the same year, Australia’s regulator revised its minimum standards for syringe drivers, again forcing Smiths Group to withdraw its syringes from sale.

Yet internal NHS papers published around this time describe Graseby’s syringes as an “essential component of British palliative care”, with tens of thousands of the devices in circulation.

The now-defunct National Patient Safety Agency reviewed incidents involving syringe drivers between 2005 and 2010, finding in 2009 that four patients had died because of accidental over- infusion of drugs. It also found 116 serious cases where units were confused or the incorrect infusion rate was applied.

It is highly unlikely that the health service has records of every suspicious death caused by a Graseby driver. Many of the patients put on the devices were seriously ill and might have soon died, so their deaths would not have triggered an investigation.

One in six deaths in Britain in 2007-8 came about after “continuous deep sedation” reflecting the so-called double effect, whereby doctors prescribe medication for alleviating severe symptoms that may cause death.

Anonymised NHS records expose fatal incidents in a clinical fashion. “A palliative care nurse from a hospice visited approximately one hour after administration and identified an error. The medication had gone through within two hours instead of 24.”

The Graseby devices could be deployed to devastating effect both accidentally, by poorly trained staff, and maliciously by those who knew how to exploit their lack of safety features.

In 2004, nurse Barbara Salisbury was dubbed “the Graseby Queen” by colleagues at Leighton Hospital because she sped up syringe drivers delivering doses to patients over a 24-hour period. She was jailed for five years for the attempted murder of two elderly patients.

Yet the scandal raises questions about other historic cases. Annie Grigg-Booth, a well-respected 52-year-old nurse, committed suicide in 2005 after being charged with murdering three patients with diamorphine overdoses. A report cleared her of personal wrongdoing, blaming “systematic failures” instead.

Last night a spokesman for the Airedale hospital in West Yorkshire, where Grigg-Booth worked, admitted for the first time that Graseby syringe drivers were in use at the time.

Her son told The Sunday Times: “She was a scapegoat for everything that was wrong at the hospital. I know what happened wasn’t her fault.” Today syringe drivers are used far less within the NHS, although last night the Department of Health would not confirm or deny if all Graseby devices had been removed.

In 2010 the NHS issued a notice advising that hospitals stop using Graseby syringes, but gave them five years to comply. It means that if the last Graseby syringe driver was removed from wards in 2015, more than a quarter of a century has elapsed since Barton’s misuse of the devices was first raised.

Written by Lois Rogers