A woman died from morphine poisoning after the ‘gross failure’ of a Doncaster doctor - who prescribed the powerful painkiller following nothing more than a telephone conversation with her daughter.
Experts say morphine should not be prescribed to anyone for the first time without a face-to-face consultation and diagnosis.
Dr Mushkoor Sheikh, of the Bentley Health Centre in Askern Road, is to be reported to NHS bosses by the Doncaster Coroner, Nicola Mundy, because of his conduct.
Ms Mundy recorded a verdict of misadventure on the death of Woodlands widow Betty Horsfield, who was 80 and suffering from breast cancer.
A pharmacist also failed to include the correct size medicine spoon with the bottle of liquid morphine, known as Oramorph.
Mrs Horsfield’s daughter, Dawn Ellis, who inadvertently gave her mum double the dosage of the opiate the day before she died, said she felt at one time she had been blamed for her mother’s death in March 2010.
“I’m just so glad someone listened. This has gone on too long,” said Mrs Ellis, of Markham Avenue, Carcroft.
“I am pleased something is going to come out of it. From now on when you ring up a doctor they should come out and do a visit. That should be the proper procedure.
“When they told me she’d died from the morphine I felt I’d be blamed.
“At the end of the day I was managing her pain relief, but it was an accident.”
Mrs Horsfield, of Great North Road, had been complaining of ‘agonising’ pain near her right breast for four days before Mrs Ellis called the health centre and asked for Dr Sheikh to visit her mother.
But he rang her back and told her he would fax a prescription for Oramorph to the chemist.
It was to give Mrs Horsfield five to 10mls up to four times a day as needed, but Mrs Ellis admitted using a dessert spoon to give her mum about 70mls the day before she died.
Mrs Ellis broke down in the witness box as she gave evidence about the dosage, and insisted she had requested a home visit from Dr Sheikh.
Tests found Mrs Horsfield had died from morphine toxicity.
In evidence, Dr Sheikh said he asked questions of Mrs Ellis and ‘listened to what was reported’ about Mrs Horsfield’s condition, and decided ‘the only option available was morphine’.
He also stated on oath that Mrs Ellis ‘didn’t ask for a home visit’.
“I thought it was appropriate to review the patient later that day or the next day. I was responding to a request for a patient who was in pain. I would still, hand on heart, do what is right for my patient,” he said.
But Mrs Ellis told the GP: “That’s wrong. I did request a home visit. I knew my mam was in a lot of pain and I wanted you to see her.”
Dr Alan Crouch, an expert witness on medical matters, said Mrs Horsfield had not been seen by a doctor for six months and ‘needed to be seen’ because she had never been prescribed morphine before.
“The bottom line is this patient needed to be seen and assessed. I think with a patient like Mrs Horsfield, who was elderly and infirm, it was mandatory.
“This amounted to a gross failure. I don’t think to prescribe morphine was appropriate. There are another analgesics, such as cocodamol, which would have been more appropriate. Not going to properly assess the patient was a serious deficiency.”
Dr Crouch also said an elderly patient should have been started on a lower dose than was prescribed by Dr Sheikh.
The coroner said the GP should have visited Mrs Horsfield and that was ‘a gross failure of care’, and there ‘absolutely should have been a follow-up call that afternoon to assess the response’.
“It seems Mrs Ellis was unwittingly giving her mother more than twice the suggested dosage,” coroner Ms Mundy said.
“I believe she failed to appreciate how much a dessert spoon contained, and was inadvertently giving her mother more than she realised.”
Ms Mundy expressed concern that a patient not seen for a long time was treated over the telephone, and she is writing to NHS England and the Lord Chancellor about the case.