Involuntary Euthanasia

Home , Harold Shipman, Involuntary euthanasia

FAM 100735-0001

This File contains information on The Dangerous Drugs Act 1948 and specific drugs - Diamorphine

THE DANGEROUS DRUGS ACT ARRANGEMENT OF SECTIONS 1. Short title. PART I. Interpretation 2. Interpretation. PART I1. Raw Opium and Coca Leaves 3. Import and export of raw Opium and coca leaves. 4. Power to requlate the production of and dealing in raw opium and coca leaves. 5. Cultivation of opium or coca leaves. PART II1. Prepared Opium 6. Export or import of prepared opium. 7. Manufacturinq. selling, using, etc.. prepared opium an offence. PART IliA. Ganja 7A. Export or import of ganja. 7B. Cultivation. selling or dealinq in or transportincl ganja. 7C. Possession of ganja_ 7D. Smoking of #ania. PART IV. Cocaine. Morphine, etc. 8. Import and export of cocaine, etc. 8A. Cultivating. selling or dealing in or transporting cocaine, etc. 8B. Possession of cocaine, etc. 9. Control of manufacture and sale of cocaine, etc. 10. Drugs to which Part IV applies. 11. Trade. etc.. in new drugs, and power to apply Part IV to certain drugs. PART V. Control of External Trade 12. Interpretation. 13. The export of dangerous drugs. 14. The import of dangerous drugs. 15. Dangerous drugs in transit. 16. Removal licences. 17. Drugs not to be tampered with. 18. Diversion ofdanqerous drugs. PART VI. General 19. Licences. 20. Exporter or agent liable for contravention regarding export. 21. Powers of inspection and seizure. 21A. Offence of using the postal services for drugs, 22. Offences and penalties. 23. Power of arrest. 24. Seizure and forfeiture of vehicles. 25. Meaning of importation and exportation under licence 26. Burden of proof. 27. Admissibility of certificate of Government Analyst. 28. Meaning of expression "conveyance" in Part VI. Schedule

What is happening? rAM 100735-0002

Recently the practice of involuntary euthanasia within the NHS, particularly at the expense of elderly patients, has attracted much attention from the media. The evidence, supported by the charity Age Concern and several patient pressure groups, suggests that doctors may have allowed elderly patients to die, and may even have hastened their deaths, as a means of easing the resource crisis within the NHS. Although there are situations in which it is not unreasonable for doctors to conclude that further treatment, including cardio-pulmonary resuscitation, will not be beneficial to the patient, BMA quidelines cleary state that the patient and / or their relatives must be made aware of this. Equally clearly, these guidelines are not being followed in a large number of cases. Instead, our elders are being allowed to die, often in fear and distress, within the very walls of the institutions they have trusted to help them. This injustice cannot be allowed to continue. I am campaigning to improve healthcare in this country. Many people have asked me why I talked to the media and exposed the truth. The answer is simple : I believe in doing what is morally correct, and in justice for patients and their loved ones. Many people suffer in silence, believing theirs to be an isolated case. Be assured that this is not so. I would like to help anyone who needs advice or assistance. Confidentiality is assured, although, with you permission, I would like to place some personal stories in view for others to see. That way, the conspiracy of silence that has cloaked this issue for so long can never again conceal the truth. I would like to hear your opinions, your feelings and your experiences of the NHS. Please send them to the address provided in the contact section, or email them to [email protected]. Thank you for your assistance. Dr Rita Pal How is this happening? The end of a patient’s life may be hastened in several ways ] ~ ~ii ill ~ ~ ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill ill iilil ~ii~I~iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii Medication stopped. Active management Withd raw Treatment stopped No feeding, decreased nursing support, no Withdraw nutrition intravenous access This drug is indicated in end stage cancer patients and for relief of heart attack pain. It Use of Diamorphine for "pain". Can be written as PRN is also a common drug given to the elderly as is needed) which may, in some cases, shorten life. You must check and question why diamorphine is being given and whether ...... !OL![ [elati~/e is t[u!!y "in Pain’’ ...... Dehydration Death due to kidney failure It is very common for doctors to place elderly patients with multiple problems on many drugs. Drugs for heart failure, particularly, may not be monitored. If levels Cocktail of drugs of ions in the blood not regularly measured, Lhis can be dangerous. A common ion is potassium, the levels of which are 3.5 - 5.5 mmol/l. Levels above this, eg 7 mmol/I, may cause cardiac arrest. Concerned relatives should request to see the patient’s notes, and obtain a full and detailed explanation of them from the staff. Some of the more common terms you may find are listed below. jDNR/i~FR ....! Do notie susci;cat e / ~lot:foires usciiaiion FAM 100735-0003

If patients are not fed orally, ensure that fluids are given by drip. May be misleading because stroke patients who cannot swallow have NBM to prevent aspiration pneumonia. Also individuals due for surgery are NBM. Always ensure there is a reason for NBM. Ask nursing staff and ensure you Nil by mouth / NBIMI / NPO relatives have intarvenous access ie canneula with fluids. The patient may suffer from dehydration which may in severe cases result in kidney failure and subsequent death. Indications of dehydration include ¯ l. Sunken eyes 2. Confusion 3. When the skin is pinched it stays pinched. NAT / No Active Treatment Drugs given will be to relieve symptoms rather that ...... atte.n)pt.to.?u.re ...... No IN access No intravenous drip to be used As many times as you like. For example ¯ staff can PRN (Pro-Re-Nata) - When required give diamorphine every half hour which would ultimately kill Tender loving care ¯ may include withholding food TLC and fluid ...... 434-6 - which can be obtained from bookshops such as Waterstones. Otherwise contact : The Pharmacutical Press, PO Box 151, Wallingford, Oxon, OX10 8QU England. Tel ¯ 01491 829 272 email [email protected] Drug Information Services ¯ 0171 955 5000 ext 3594 /5892 Poisons Information Services ¯ 0171 635 9191 Diamorphine Diamorphine, otherwise known as Heroin, is usually used in pallative care and heart attack patients. It is injected subcutaneously (under the skin) or intravenously (through a vein). Placing it through a vein makes the drug act faster. Its effects are multiple. Used usually for pain relief, it can also depress respiration thus decreasing your drive to breathe. It also relieves anxiety eg in heart attack patients. It is a drug that is useful in heart failure enabling the load of the heart to be less thus relieving the problems of the failing heart coping with a large amount of blood. It can be written as a PRN (dose) which is as "as is needed". Being a controlled drug, it has to be signed by two people when giving it. Usual doses are 2.5-5mg. It may be placed in a syringe pump, usually in pallative care, (cancer patients) to relieve pain and distress. Diamorphine is contraindicated in people with respiratory conditions because it has been known to cause respiratory arrest. Petition for an Independent Public Inquiry The elderly have fought our wars for us, have paid their taxes, have made this country into what it is today. The NHS has been shown to treat its elderly with contempt and neglect. There has been a public outcry regarding the recent revelations of involuntary euthanasia within the NHS. We believe that the Government should institute an immediate and wide ranging public inquiry into these practices. FAM 100735-0004

We intend to present the Government with a petition that it cannot ignore. Please support this campaign by adding you name to our petition. Simply type your name and email address in the boxes below and click the Send button.

Contact Do not allow this conspiracy of silence to continue! I am happy to help anyone who would like advice or assistance. Please feel free to contact me with your opinions, your feelings and your experiences of the NHS. All correspondence will be treated in confidence, although, with your permission, I would like to place some personal stories in view for others to see. Email : [email protected] NHS Exposed’s Diamorphine Series We present the NHS Exposed Diamorphine Series. Involuntary Euthanasia is more common than the medical profession would have us all believe. The cases are shut down through the police because it will be "too terrifying for the public". Why did Dr Harold Shipman remain undetected for so many years? This was due to currently unresolved flaws in the system. We do not wish to instil fear but make the public think about this issue. Most doctors in the NHS are caring and compassionate but the patient is unprotected from those who have ingrained personality deficits. There are still doctors who are calculating and wish to terminate a life in order to have an undisturbed night. The medical profession protects its own. It protects the reputation of the establishment at the cost of lives. These doctors are not Harold Shipman but simply discriminatory in their attitudes. "Well she is old so what kind of quality of life does she have?" "Well, he is disabled so what quality of life does he have?" Doctors are playing God because the GMC is clearly inept at protection and the establishment protects these doctors until it is too late. We will present a series of stories which elucidate the extent of the problem. The first case concerns the mother of Olwyn Bowen who was killed by an overdose of diamorphine. This case is from a sleepy town in Wales where the Bowen family had to learn to fight a system that was more corrupt than they had envisaged. They have fought this case for many years now, and it has featured in the Daily Express with comments from Dr Treloar. This could happen to any of us. It was just a matter of probability that it happened to the Bowens. Click here to read more about this case. The second case concerns Mr David Glass, a 14 year old gentleman with physical and learning difficulties. A few years ago this pleasant little boy was the subject of endless newspaper articles. What was the reason for this? David had been admitted into St Mary’s Hospital Portsmouth with a chest infection. Diamorphine was administered contrary to the wishes of the mother Mrs Carol Glass. Click here to read more about this case. Thank you for your time. If you have any cases you wish to share with us, email us at enquiries@nhs- exposed .com 29th July 2001 DIAMORPHINE DEATHS STILL CONTINUE A number of complaints from relatives prompted the Daily Telegraph to report this story in their article The hospital in question this time was Gosport War Memorial Hospital which is based near Portsmouth. FAM 100735-0005

An elderly lady was prescribed Diamorphine. Hampshire police confirmed at that time that they were continuing investigation although one case had been sent to the Crown Prosecution Service. Approximately nine complaints were made. Gillian Mackenzie, whose 91-year-old mother died at the hospital after being prescribed diamorphine, contacted police in 1998. Solicitors stated that there was" insufficient evidence for charges of unlawful killing". This is a common trend seen in many cases. Infact, you will note through our Diamorphine series that cases end in this way. We cannot speculate as to the reason for this but it seems that it is a decision made on public policy rather than scientific fact. The problem ofcourse is that we have read the medical records in a few cases ( not this particular one) and noted that despite scientific evidence, the police or the CPS decided that there was" no case to answer for". Now, Olwyn Bowen’s mother ( Case 1 of this series) died of Diamorphine administration. A competent GP stated that he felt her life was shortened yet the police felt that there was "insufficient evidence". The same situation has occurred in Stafford where David Kidney is MP. He asked a question in parliament about the case of Mr X .Despite overwhelming scientific evidence, the case was stated to have " insufficient evidence" for CPS prosecution. Mrs Mackenzie, 63, of Eastbourne, East Sussex, told the Telegraph : "1 am a realistic woman. I knew there was a chance of my mother dying when she was admitted to hospital. It is the manner she died that shocked me. I will never know what would have happened if she had not been prescribed diamorphine but we must ensure that all the circumstances of these deaths are fully explained." She added: "1 am glad the police are investigating these cases at the hospital. They are all similar to my mother’s and we must get to the bottom of what was happening." The problem is who exactly is going to get to the "bottom of it" if there maybe an unsaid pubic policy to prevent cases from success? Afterall, doctors have been allowed to practice like this for many years. It is easier to think of Dr Shipman as an isolated incident as opposed to gradations of abuse of Diamorphine. Would it be so unthinkable to consider that to protect the public from fear of doctors, these cases are not seen through? It is a public fact that Mr Blair believes in appearances. It is also a known fact that should these cases be catapulted into the public domain with a verified prosecution, it would have implications on the lack of protocols governing the use of Diamorphine and also the loss of faith in doctors and the NHS. It should be noted that despite the deaths in Hyde, the scattered deaths throughout the country, there is still no move to regulate Diamorphine. What has the Department of Health done to protect the public? It writes nice pretty documents and the GMC scream "revalidation" and then under their breath just like Fiddler on the Roof, they whisper" tradition" but what is happening in the grass roots of medical practice? The searching question is does the Department of Health have a motive in shutting down cases concerning Diamorphine? Is this the legacy of post Shipman public policy? The other side of the argument states that without a deterrent, this form of management with diamorphine will continue for the foreseeable future. Diamorphine seems here to stay. Without regulation, it is a dangerous drug in the wrong hands. That is a fact. The legal system protects the medical system as seen in David Glass’s story. The government protects and nurtures them both. The common factor in all these establishments is the protection of reputation at the cost of people’s lives. While we here at NHS Exposed are condemned for what we write, we know the truth about the NHS because we work in it. The government may wish to brush us off as insane or ignore what we say but the truth remains - these cases speak the truth to everyone. Questions need to be asked by a public who is currently being lulled into a haven of false security. Where does the elderly or disabled person’s rights lie in this Goliath of a system set to fail patients?It has nothing to do with conspiracy theories, it has something to do with protecting the reputation of the government, something that Mr Blair clearly believes in. It has to do with simple human behaviour to protect their inept glass houses Are these cases too much of a coincidence or are we observing a silencing of the truth? NHS Exposed. 1994 Young boy is killed by Diamorphine. Doctor is not sent to prison. This article was present in the Independent in 1994 a long time before anyone was made aware of the drug. A young boy and a simple operation with a high dose of diamorphine yet this level of recklessness on the part of the doctor failed to result in imprisonment. This is the attitude of the justice system which in effect provides doctors a safety net to do whatever they wish. We wonder what the GMC did in this case? FAM 100735-0006

The Independent of England, 9 July 1994. A FAMILY doctor who killed a nine-year-old boy by giving him a massive overdose of a pain-killing drug during a circumcision operation, was given a one-year suspended jail sentence yesterday. Dr. Mahbubul Alam, 59, of Handsworth Wood, Birmingham, admitted the manslaughter in July 1991 of Raju Miah, of Smethwick, who died in hospital six days after being given diamorphine (heroin). Timothy Barnes QC, for the prosecution, told Stafford Crown Court that the boy was taken for the operation by his grandfather. Dr. Alam, who had performed four circumcisions that day, administered 10mg of diamorphine, "five to six times the appropriate dose." Mr. Barnes said: "Raju was given 10mg of diamorphine, which sedates the brain and also tends to depress breathing. After the operation the boy was still unconscious and when he was driven back to the family home, Dr. Alam tried to arouse him by sprinkling water on his face and lightly smacking his face." He said shortly after the doctor left, the boy’s condition worsened and he was taken by ambulance to hospital. After six days, he was certified brain dead and the life-support machine was switched off. Mr. Barnes said the cause of death was narcotic poisoning. "The choice of drug was wholly inappropriate and on a boy of his age was grossly negligent," he said. Mr. Justice Buckley said: "1 only hope Raju’s family can find it in their hearts that sending Dr. Alam to prison...would serve no public interest and do nothing good for the memory of Raju." DAVID GLASS SURVIVES DIAMORPHINE ADMINISTRATION Mr David Glass is a 14 year old gentleman with physical and learning difficulties. A few years ago this pleasant little boy was the subject of endless newspaper articles. What was the reason for this? David had been admitted into St Mary’s Hospital Portsmouth with a chest infection. Diamorphine was administered contrary to the wishes of the mother Mrs Carol Glass. The hospital stated it was in his "best Interests to allow him to die without distress or pain". What would any relative or mother do when faced with their child’s death caused by a drug? Mrs Glass stopped the Diamorphine pump. The police were called in by the hospital in order to stop the actions of the relatives. The relatives did all they could to protect David Glass under these circumstances. The relatives were later convicted for violent disorder and causing causing actual bodily harm to doctors during this dispute. Hospital Doctor reported this incident without the mention of Diamorphine as the provocation factor. Provocation is an important fact in this case. What would you do faced with your son or nephew dying by the hand of a doctor? Would you remain silent and stand back while the little boy turned blue or would you do everything in your power to ensure the child was saved? In all honesty, the input of the family saved David Glass’ life. The medical profession has been presented with a skewed version of the events. Violence is not to be condoned but provocation and attempted murder is certainly not to be accepted either. David has celebrated his fourteenth birthday. Would this have been possible without the intervention of his family? Carol Glass did what she did out of the love that any mother has for their child. For all those doctors who judge this case - you would do the same for your child. Any parent would. David Glass survived where many do not. This should be a lesson to the medical profession to cease playing God and to provide patients and their relatives with the choice of life or death. We wish Mr David Glass the best of luck for the future. His story is best presented from his own website. His site has a number of excellent well structured sections where the events are set out logically and in chronological order. We hope you will bookmark his site for the future as his case is currently in the European Courts of Human Rights. For more information see : http://www.members.tripod.com/davidqlassl/ Government to consider public inquiry into death of 86- year-old grandmother. From Wales on Sunday, 17th Feb 2002 THE Government is likely to decide this week whether to launch an inquiry into allegations that an 66- year-old Welsh grandmother was killed as part of an unacknowledged "involuntary euthanasia" policy in the NHS. Olwen Gibbings, who lived at Aberbargoed, near Caerphilly, died in 1996. She was admitted with a leg ulcer. They say her medical records suggest that on the day she died she was given a higher dosage of diamorphine than Dr Harold Shipman used in killing his patients. FAM 100735-0007

Her daughter and son-in-law, Olwyn and Mal Bowen, are convinced that her death was a direct result of large doses of the heroin-based painkiller diamorphine being pumped into her body. A police investigation into Mrs Gibbings’ death resulted in a decision by the Crown Prosecution Service that there was insufficient evidence to bring criminal charges against the medical staff involved. But the Bowens maintain there are clear grounds for believing that Mrs Gibbings died unnecessarily. They have received support from unexpected quarters. Dr Michael Irwin, who chairs the pro-voluntary euthanasia group Doctors for Assisted Dying, wrote to Mrs Bowen after she sent him the case papers. His letter stated: "Having carefully reviewed all the documentation you have sent me, I believe that involuntary euthanasia was performed on Mrs Gibbings. "Involuntary euthanasia can be defined as ending someone’s life who could consent but does not. Such an action is indistinguishable from criminal homicide and the claim that the motive for killing is in ’the best interest’ of the patient is irrelevant." Dr Irwin estimates that the deaths of at least 100,000 elderly people in England and Wales each year may be attributed to euthanasia, of which no more than 3,000 are voluntary. He argues that doctors are able to reconcile euthanasia with their duty to preserve life by relying on the concept of "double effect", under which they give drugs to relieve pain even if the result is to shorten a patient’s life. Dr Irwin’s letter to Mrs Bowen concluded: "The ’excuse’ of double effect allows the possibility of slow euthanasia, and as such is performed today in general practice, in hospitals and nursing homes, and in hospices throughout the UK." Mrs Bowen, who lives at Blackwood, near Caerphilly, said: "After my mother’s death we obtained her medical records. They suggest that on the day she died she was given a higher dosage of diamorphine than Dr Harold Shipman was in the habit of giving to the patients he killed. "When she went into hospital she was sitting up in bed reading a magazine. But after they gave her the diamorphine she was gasping for breath. "On her medical records her age, 86, was circled. That says it all, I think. "There are also the letters DNR, meaning Do Not Resuscitate. Yet this issue was not discussed with us or with my mother, who had no reason not to want to live. When she went into hospital she thought she was going in for routine treatment to her leg ulcer." While in the hospital, which has since closed, Mrs Gibbings caught the super-bug infection MRSA. Days after her death, laboratory test results confirmed that she did not have the most virulent strain of the infection, but Type B, which is treatable with antibiotics. Their strong feeling that Mrs Gibbings had died unnecessarily led the Bowens to set up a telephone helpline for the relatives of elderly patients who died in similar circumstances. They were contacted by hundreds of people from all over Britain, many of them with harrowing stories. Mrs Bowen said: "When deaths occur, people feel isolated and overwhelmed. If relatives wish to pursue a complaint they find themselves up against a medical bureaucracy that supports the status quo. "Each case is treated singly and therefore general issues of principle are not considered. "We believe there is a clear case for a public inquiry into the increasingly widespread belief that involuntary euthanasia is a common occurrence in the NHS." In 1999 the Conservative MP Ann Winterton introduced a Bill to the House of Commons intended "to halt the slide towards the acceptance and practice of euthanasia by making it clear to doctors that they cannot intentionally bring about the death of their patients by action or omission". The Bill fell because it ran out of debating time. Mrs Bowen has passed details of dozens of cases where relatives believe involuntary euthanasia occurred to her MP Don Touhig, a minister at the Wales Office. Mr Touhig has had one meeting about the matter with Health Minister Hazel Blears. He has told the Bowens that he expects to have another meeting with her this week when she is likely to respond to his request for an inquiry. See also : British National Health Service accused of bias against elderly Watch out, you old chickens! I welcome the recent news of an increase in the state pension, but have misgivings as to whether it will be good news for all pensioners. The reason for my scepticism is that for the past four years my wife and I have been campaigning for justice for my late mother-in-law, who was a victim of involuntary euthanasia. FAM 100735-0008

Throughout our campaign we have encountered all forms of rule bending by every authority that we have approached, including NHS trusts, the GMC, the Police Force, the CPS and the Police Complaints Authority. Whenever we appealed to the government concerning this blatant rule bending, we were told that they could not intervene in the decisions reached by any of the authorities involved. Since 1996, I have spoken with the relatives of hundreds of victims, who suffered the same fate as my late mother-in- law, only to discover that they had encountered the same problems with the various authorities, including the government. I believe that my late mother-in-law and many other elderly and vulnerable people have died as a direct result of decisions taken by unethical senior members of the medical profession, for purely economic reasons. It is my opinion that successive governments have been well aware of this practice, but have chosen not to intervene and act against these despicable people. I believe the reason for their inaction is that although these medical professionals are clearly breaking the law, as well as the Hippocratic oath, they are also boosting the economy, with significant savings to the government on medical treatment, long term care and pensions etc. In my opinion, a suitable analogy of the government’s attitude to these unethical medical professionals would be that of a poultry farmer (the Government) who employs a guard dog (senior medical professional) to protect and care for his flock. The dog is unable to protect all of the birds, as there are far too many for one guard dog, so the dog reduces his workload by killing off the odd old non-productive bird (elderly or vulnerable patient). The poultry farmer is fully aware that the guard dog is killing birds. But refuses to punish the dog in any way, because of (a) The savings he is making, by only having to feed one dog and (b) The substantial savings he makes from no longer having to house, feed and care for old non-productive members of the flock. I believe that some unethical members of the medical profession may regard an increase in pension as raising the bounty on our elderly and vulnerable citizens, within the safe sanctuary of the government’s blind eye! Mal Bowen. WHAT DOES EUTHANASIA MEAN? The article below was something I myself came across by accident on the world wide web. The writer’s work impressed us so much, we asked the author to write for our site. This is the most comprehensive article that has the combination of philosophy and science as well humanity that makes it one of the best works I have seen on the topic that is understandable to the public. In the light of the UKjournalists who have not covered this topic fully - nor have they taken the time to understand the medical ethics of the subject, we certainly do applaud Isis Kearney for a work which is certainly something to be proud of. We thank you for your contribution which will be useful to many individuals across the world. NHS Exposed Team

WHAT DOES EUTHANASIA MEAN? Written By: Isis Kearney isiskearney@_qwest.net At some point in our lives we will all depart this fine world, but do we have to suffer until that day comes? Unfortunately a vast majority of our society believes it’s wrong to consider euthanasia as an option. Throughout history we have fought for the freedom of choice, like abortion, the right for women to vote, and the right for gays and lesbians to marry, just to name a few examples. Euthanasia should be considered a pro-choice decision, as long as physicians have guidelines that they must follow. Euthanasia may not be right for everyone, based on their religious beliefs, cultural background, or their upbringing. That dose not necessarily mean, that euthanasia is wrong for everyone. The word Euthanasia originated from the Greek language: Eu means "good" and Thanatos means "death". The definition that the Netherlands State Commission uses is "the intentional termination of life by another, at the explicit request of the person who seeks death as a last resort "(NSC). That is, the term euthanasia usually implies, nevertheless the person who wishes to end their lives due to great agony must initiate the act. However, many people define euthanasia to include both voluntary and involuntary termination of life. Like so many other terms in our language euthanasia has many meanings. The result is mass confusion among our society. FAM 100735-0009

Presently there are four complicated categories that represent euthanasia. The first, is voluntary euthanasia: in which a patient voluntarily brings about his or her own death with the assistance of a person, typically a physician (Encarta). In this incident, the act is considered suicide (intentional self- inflicted death). The patient actually consents to his or her own death either verbally or through a living will. In the case of Don "Dax" Cowart, he verbally consented to his own death, but the physicians and his family denied him "the right to die". It was considered ethically wrong in their eyes. In their opinion they saw it as saving a young man’s life. They saved his life, but his quality of life will never be the same. As the year went by he endured excruciating treatments, which did not fully heal him. Don not only lost his sight, but all mobility in his hands. His healing process took more than a year; in fact it took six prolonged and agonizing years. Not to mend the physical scars, but the mental ones that followed his ordeal. Many people argue that voluntary euthanasia is "playing god". Then we should also consider that every time a doctor brings a patient back to life, he is "playing god" in a medical way. The second type is Involuntary Euthanasia: this term is considered to be murder, for the fact the patient is unable to give a written or verbal consent (Encarta). There are many cases of people that are involved in some type of accident, where the patient is considered brain dead or comatose. Numerous states have established a definition of brain death. The point when certain parts of the brain cease to function in a normal way, this is the time when it is legal to shut down a patient’s life-support system, with the consent of the patient’s relatives. However, there is an escalating problem among our Nation’s Health Services program, which provides health care at no cost for individuals who are unable to afford some type of health insurance (NHS). Elderly patients that are not terminally ill are having their lives hastened by doctors, because they have become a burden on society. Basically they are trying to cut the cost of caring for the elderly. If euthanasia is legalized throughout the United States, involuntary euthanasia will have to have very strict guidelines. This will ensure that innocent people do not loose their lives, due to lack of money or that they have become a burden on society. In the graph below are some common ways that a person’s life may be hastened. THE METHOD THE MEANING THE THE MEANING METHOD Withdraw Medication stopped, Active management stopped Treatment ...... Withdraw No feeding decreased nursing support, no intravenous access Nutrition Use of Can be written as PRN (as often as you like) This drug is indicated in the end Diamorphin stage of caner patients and for relief of heart attack pain. It is also common drug e for~ipa!ni,, given to the elderly, ~,!lich rnayir~ s0rne cases, shorter1 life~ ...... 19e.l~.ycl.r.at!o.n..i Death due to kidney failure It is very common for doctors to place elderly patients with multiple problems on many drugs. Drugs for heart failure, particularly, may not be monitored. If levels Cocktail of of ions in the blood are not regularly measured, this can be dangerous. A drugs common ion is potassium, the levels of which are 3.5-5.5 mmol/i. Levels above this eg7 mmol/I may cause death...... !Phar aceu !ca! Press) ...... Active euthanasia also know as physician assisted suicide: involves painlessly putting individuals to death by administering some type of lethal dose of medication (Encarta). Active euthanasia is done at the patient’s request. This has caused a widespread debate, for many decades. In the sixteenth-century, philosophers began to challenge religious beliefs on suicide. Michel De Motaigne, a sixteenth-century philosopher, argued that suicide was not a question of Christian belief but a matter of personal choice (Aquinas). There are many religious that condemn active euthanasia! The Islamic Center of Southern California states that "since we did not create ourselves, we do not own our bodies... Attempting to kill oneself is a crime in Islam as well as a grave sin. The Qur’an says: ’Do not kill (or destroy) yourselves, for verily Allah has been to you most Merciful.’ (Quran 4:29)... The concept of life not worthy of living does not exist in Islam" (ICSC). While there are religious organizations that express disapproval of euthanasia, I found some that support active euthanasia. The United Church of Christ and the Methodist Church have made pro-choice statements on the US West Coast (Charlesworth). The "Anglican Unitarian, Methodist, FAM 100735-0010

Presbyterian, and Quaker movements are by far the most liberal, by allowing the patient to make the decision for active euthanasia" (Religion). Though active euthanasia is gaining acceptance from many religious organizations, it is not legally practiced in the US, expect in Oregon. Passive euthanasia means to hasten the death of a patient by withdrawing all means of medical support, which allows the body to naturally die on it’s own. Passive euthanasia may sometimes be confused with voluntary euthanasia, for the reason that it is usually expressed in some type of living will. The most common form of passive euthanasia is to give the patient large doses of morphine to control pain, which usually suppress respiration and causes the patient to die much earlier. Typically these procedures are performed on terminally ill, so that natural death will occur sooner and their suffering may end (New England). It is also performed on individuals who are in a Persistent Vegetation State-individuals with massive brain damage who are in a coma from which they will not regain consciousness. This form of euthanasia seems to be more accepted among our society. A fact that is very disturbing to me is the suicide rate among the elderly. The rate is much higher among the elderly, due to debilitating effects of physical illness, loss of social roles and untreated depression. We must be willing to give the elderly a choice in how they may die, so they do not become another statistic in our society. As we can see there are various meanings of euthanasia, which gives a dying patient an option for how they will depart our world. Some people may not agree with euthanasia at all and I am not trying to change their beliefs. But, for the ones that do support euthanasia, myself included; we should be able to decide how we will depart this world. This is not a right or wrong decision; it should be considered a pro- choice decision. However, if and when euthanasia is legalized, the government will have to implement very strict laws, so physicians do not abuse euthanasia. WORK CITED Aquinas, Thomas "Suicide and Early Christian Values" In Suicide and Euthanasia, ed. Broody 142-44 T.L.Beachamp Charlesworth, Max "Bioethics in a Liberal Society", Cambridge Univ. Press, Oakleigh, (1993) "Definition of Active Euthanasia" Microsoft Encarta 2000 1993-1999 Microsoft Corporation. "Definition of Euthanasia" Microsoft Encarta 2000 1993-1999 Microsoft Corporation. "Definition of Involuntary Euthanasia" Microsoft Encarta 2000 1993-1999 Microsoft Corporation. "Definition of Passive Euthanasia" Microsoft Encarta 2000 1993-1999 Microsoft Corporation. "Euthanasia" Southern California Islamic Society [Online] "Involuntary Euthanasia" [Graphic] the Pharmaceutical Press "Definition of Euthanasia" Netherlands State Commission on Euthanasia. > [Online] at: http://n etherlands.statecomm/edthanasia.com "Passive Euthanasia" New England Journal of Medical [Article] 1998-April-23 "Religion and the Right to Die" [Online] at: http:/hNWWW.euthanasia.orq/reliflion.html Euthanasia debate at: http://www.leeds.ac.uk/disabilit¥- studies/a rchive uk/Davis/persp%20on %20euthanasia.pd f British Health Service Doctors Accused of Involuntary Euthanasia By Liz Townsend

Allegations that elderly patients and patients with disabilities are being killed by involuntary euthanasia have caused a firestorm of controversy in Great Britain, as families across the nation come forward with stories of how their loved ones were given fatal doses of painkillers or "do not resuscitate" (DNR) orders without their agreement. The National Health Service (NHS), a health system run by the national government, provides medical care in Britain. According to families, doctors, and patient advocate groups, tight funding and high demand often lead doctors and hospitals to ration treatment of patients whose "quality of life" is deemed too low, the Daily Telegraph reported. "There are severe pressures on beds and in order to relieve this there may be a tendency to limit care inappropriately where you feel doubtful about the outcome," Dr. Adrian Treloar told the Telegraph. "Are the elderly being served FAM 100735-0011

properly? No, tlaey are not getting what they deserve and I think they are being sold short. If old people start to resist early discharge they are seen as an encumbrance." Other doctors have seen this firstlaaxld. "I have witnessed doctors who want to keep beds clear by withdrawing treatment or actively assisted in death to the point where it becomes involuntary euthanasia," Dr. Rita Pal told tlae London Times. She told of one case where a doctor ordered medications witladrawn from an 89-year-old stroke patient, who was conscious but unable to speak. "This man was actually conscious and could hear us," Dr. Pal said. "The doctor said, ’We need tlae bedstop all his medication.’ They stopped the medication and at about 9:30 p.m. he started getting short of breath. I held his hand and said, ’You will be all right.’ I was sickened by tlae whole episode." The Times reported tlaat Dr. Pal disobeyed orders and gave tlae patient medication to help him breathe, but tlae man died. Members of 78-year-old William Heaford’s family told their story to the Telegraph. Heaford entered the Royal Oldham Hospital after falling and cutting his head. He had to wait with a bleeding head more than four hours to be examined. Once he was admitted to tlae hospital, he quickly began to lose weight. His family told the Telegraph that "when nursing staff brought his food tlaey left it out of reach and did not help him to cut it up or eat it." When they complained about tlais and other evidence of neglect, hospital staff told them, "Your fatlaer is not tlae first priority on this ward, there are otlaer patients that come before him you know," tlae Telegraph reported. Heaford died on February 16, 1999, five weeks after admission to tlae hospital. Even British supporters of assisted suicide admitted tlaat these abuses are occurring. Michael Irwin, chair of Doctors for Assisted Dying, examined the records of 86-year-old Olwen Gibbings, who died in 1996 of septicemia. According to the Telegraph, her medical notes included a DNR order and showed that she received infusions of diamorphine, a heroin-based painkiller, which neither she nor her family authorized. "Having carefully reviewed all the documentation you have sent me," Irwin told Gibbings’s daughter, Olwyn Bowen, according to tlae Telegraph, "I believe that involuntary eutlaaxmsia was performed on Mrs. Gibbings. "In the U.K. there is every indication that both involuntary eutlaaxmsia and non-voluntary euthanasiadeath brought about on an individual who has no capacity to understand what is really involved.., happen much more frequently." Once families of elderly patients who received questionable care came forward, relatives of patients with disabilities also began to speak out. Carol Glass, whose 12-year-old son David has cerebral palsy, told the Telegraph that doctors at St. Mary’s Hospital in Portsmouth ordered that David should be given diamorphine and a DNR order and left to "die with dignity" when he was admitted witla a chest infection. Mrs. Glass did not know about this decision until she insisted on seeing her son’s medical notes, according to the Telegraph. David survived his hospital stay, and his mother now cares for him at home. Unfortunately, not all parents are successful in reversing doctors’ decisions to let a patient witla a disability die. A family who asked not to be identified told the Mirror that their 18-month-old daughter died in a hospital after doctors refused to help her breathe with a ventilator or give her antibiotics. "Her parents tried to reverse this decision in the courts," a spokeswoman for Mencap, a mental health charity, told the Mirror, "but tlae judge said that, because she could not raise her head off the pillow, her life was not worth saving." Concerned Britons formed a group called SOS-NHS Patients in Danger to monitor and try to stop these abuses. Spokeswoman Julia Quenzler told tlae Telegraph that her group is plaxming to sue the government for failing to protect vulnerable citizens. "We are hearing from more families whose children were denied treatment for no other reason tlaaxl tlaat tlaey were disabled, and strangers decided they had no quality of life," she said. "They had no chance." Member of Parliament Ann Winterton introduced a bill in late 1999 intended to "halt the slide towards the acceptance and practice of euthanasia by making it clear to doctors that they cannot intentionally bring about the deatla of their patients by action or omission," the Telegraph reported. The House of Commons debated the bill on April 14, but those opposing the bill became very vocal and the allotted time for debate raw out. It was then placed in a long line of bills waiting for future debate, meaning it has "almost no chance of becoming law," according to tlae BBC. "The terrifying cases coming out of Great Britain should serve as a warning to us in tlae United States botla of the dangers of rationing, and of legalizing direct killing as eutlaanasia," said Burke Balch, NRLC director of medical etlaics. "Rationing imposed by managed care organizations or by some Medicare restructuring proposals could easily make such discriminatory denials of lifesaving treatment, and even food and fluids denials tlaat are already occurring here as common in America as in the U.K." FAM 100735-0012

Shipman victims ’would have died in minutes’

Special report: Harold Shipman

Staff and agencies Thursday June 21,2001

The victims of serial killer GP Harold Shipman would have been dead within 10 minutes of a lethal injection of pain killers, a pain relief expert testified today. On the second day of the public inquiry into Shipman’s crimes, Dr Henry McQuay, professor of pain relief at Oxford University, said that 30mg of diamorphine would take effect within minutes, causing the patient to stop breathing. Shipman, 55, of Hyde, Greater Manchester, was convicted in January last year of murdering 15 elderly female patients with lethal injections of diamorphine. The inquiry in Manchester, chaired by high court judge Dame Janet Smith QC, is investigating the deaths of another 459 of his former patients and is expected to last about two years. Today Professor McQuay he told the inquiry that the effects ofdiamorphine would be worse on elderly people. He said: "If you do not breathe for three minutes then your brain will be starved of oxygen and you will die ." Professor McQuay said to cause someone to stop breathing 30mg of diamorphine would have to be injected within five minutes. The standard dose used to inject an adult for acute pain relief would be 10mg of morphine or 5mg of diamorphine repeated every four hours. "The greatest amount I have ever administered is 15mg of diamorphine over about five minutes to a large Swedish man who had been out cross country skiing and had broken his femur (thigh bone)." He said there was not much call for GPs to inject diamorphine these days. "The amount of injections that a GP gives has gone down partly because of the use of paramedics," he told the inquiry. Yesterday Dame Janet heard how one elderly man died in August 1996 while left alone for five minutes with the doctor while his brother was in the kitchen. Richard Lissack QC, who is representing nearly 200 of the families, said Kenneth Smith, 73, went into the kitchen of the home he shared with his brother, Sidney, on Garden Street, Newton, to give him some privacy with Shipman. When he returned five minutes later, 76-year-old Sidney was sitting dead in his favourite chair, although he had been shopping that morning. Only four months later Kenneth too was dead after a visit from the doctor, the inquiry was told. Yesterday the inquiry was told that Shipman’s career could have been cut short if the home office and General Medical Council had taken tougher action against him after he was convicted of forging prescriptions for massive quantities of pethidine in 1975. The doctor became addicted to the painkilling drug in his first practice in Todmorden, West Yorkshire, as a young, enthusiastic GP. Despite his conviction, a committee of the GMC decided no further action should be taken against him, a decision backed by the home office. The hearing was adjourned until tomorrow when Dr John Grenville, an expert on GPs, is due to give evidence. Photo gallery The story jn pictures Audio Angelique Crisafis in Hyde. (2mins 03) Harold Shipman is questioned by the police Read the transcript Government audit Download the report Extracts from the report The trial Complete case reports FAM 100735-0013

Related articles 21.06.2001 : Killer fooled authorities for 24 years 11.01.01 : Police investigate deaths of more Shipman victims 08.01.01 : Minister admits watchdoq is not Shipman-proof 05.01.01 : Safequards were not tough enouqh, admits department of health Useful links The Shipman inquiry Greater Manchester police General Medical Council Department of health The most appropriate use of syringe drivers

Think Is the patient unable to take medicine by mouth? Are there alternative routes of drug administration? The most appropriate use of syringe drivers Find Out Assess the patient regarding ¯ present symptoms ¯ physical, mental and conscious state ¯ ability to swallow ¯ present oral treatment schedules. The most appropriate use of syringe drivers Action Explain the use of the syringe driver to the patient. Plan the patient’s 24-hour parenteral opioid schedule. ¯ Use diamorphine in the syringe driver. Diamorphine is the opioid of choice in continuous subcutaneous infusion: its high solubility reduces the volume of diluent necessary. ¯ The 24-hour dose of diamorphine to be administered by the syringe driver is equivalent to one-third of the total oral morphine given to the patient over the 24 hours preceding the use of the syringe driver. The 24- hour parenteral dose of diamorphine = last 24-hour dose of oral morphine divided by 3. ¯ Calculate the 24-hour dose of compatible anti-emetic and/or antispasmodic. ¯ Prepare the syringe driver for action. ¯ Choose an appropriate site for subcutaneous infusion and insert the needle. ¯ Start the pump. It is important to ¯ explain to the patient/relative how the pump works ¯ reassure the patient of freedom of mobility while on the pump ¯ consult with hospice staff for advice. Check site of inj ection daily for signs of induration and inflammation. Check effectiveness by looking at indicators of good performance, including FAM 100735-0014

¯ satisfactory pain control and no breakthrough pain ¯ satisfactory control of other symptoms ¯ patient satisfaction ¯ infusion running to set time ¯ no leaks ¯ no signs of skin irritation. The most appropriate use of syringe drivers More Facts and Comments The oral route is the best way of taking opioids and other medicines in advanced malignancy. However, this may not be feasible, as in ¯ persistent nausea and vomiting ¯ dvsphagia ¯ intestinal obstruction ¯ profound weakness ¯ falling conscious level or coma. Alternative routes Rectal route This should be considered before moving to the next alternative. Continuous subcutaneous infusion (CSCI) Administration of drugs by continuous subcutaxleous infusion, via a portable syringe driver or oflaer infusion device, is a valuable option for symptom control. Advantages of continuous subcutaneous infusion include ¯ maintenance of plasma concentrations of drugs ¯ avoidance of 4-hourly inj ections - which may be inconvenient, painful and disruptive ¯ maintenance of patient’s mobility and independence. Remember ¯ ifbreakflarough dose is used frequently, reassess the prescription before the syringe driver is reloaded ¯ for breakthrough pain, prescribe one-sixth of the total daily dose of analgesia. Thus, if the syringe driver contains 200 mg diamorphine for 24 hours, flae breakthrough dose is 30 mg diamorphine subcutaneously, as required ¯ bowel caJ:e

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Statement - police 123kB 10/01/ 1998

::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~/~8~::~ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~~ii~iiiiiiiii~ii~iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~iiBiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~i~iiiiiiiiiiii GD10 Other 0300 Police Statement of Ghislaine Brant re Keith Harris Refs 1 Statement - police 42kB 16/12/ 1998 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~:: ~ :: ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~: ~::: :::::::::::::::::::::::::::: ~t~e~

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GD10 Other 0500 Police Statement of 6hislaine Brant re Peter Neal ...... Refs 16/12/ Statement - police 49kB 1998 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::: 6::0O:~::~::~o|~e~::siaie::me~1~i~::~::~6~s|a~::~::B~fa~1~i~::~e~::~a~e$~::~a~da~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:

...... GD10 i ii.i. i.iii ...... Other 0900 Police Statement of Ghislaine Brant re Frank Crompton ...... Refs FAM 100735-0019 FAM 100735-0020

......

GD13...... ii iii iiii ...... Other 0100 Police Statement of Ruth Cooper re Frank Crompton 1 .R..e.[s. 02/01 / Statement - police 56kB 1999 G D:: ~ :: ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~:: ::::::::::::::::::::::::::::::::::::::: ~::~::~::~::~ice~::S~a~e::men~::~{::~Ma~::~r~mpt~n::~::~re~::F:mnk::~::Gr~mpt~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::U~n~:~:~

Statement- police 44kB 27/04/ 1999 ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~3~/~5~::~iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii;i:iiiiiiiiiiiiiiiiiiiiiiiiiiiii?iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii?iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii;iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii::i::i::i::i::i::i::i::i::i::i::i::i::i::i::i::i::i::i::i::i i::i::i::i::i:: iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~~ii~iiiiiiiii~iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~iiBiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~i~iiiiiiiiiiii GD17 Other 0100 Police Statement of Dianne Fleet re Keith Harrison Refs 1 Statement - police 53kB 15/01/ 1999 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~:: ~ :: ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~: ~::: ::::::::::::::::::::::::::::

...... I0N~~

GD18 Other 0200 Police Statement of Marion Gilchrist re Mrs Jackson ...... Refs

10/01/ Statement - police 80kB 1998

[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[~[[~ ~ ~[~[[ iiiiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiiiii~ ~ iiiiiiiii~ ~iil i ~ii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiiiii ~ ~ii~ Biiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiiiiii ii~i~iii ii iiii iiii GD18 0400 Police Statement of Marion Gilchrist re James Arrandale r--O--t--h---e---r Refs 1 15/01/ Statement - police 46kB 1999 ii ii.ii.ii i.i .ii. ii .i .ii. ii. .ii. i’ .ii .ii.i .ii.ii .i.i ii.iiN . .ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.ii.iiN iii.ii.ii. :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: Ni ii.i. i.iii ...... GD18 Other 0600 Police Statement of Marion Gilchrist re Kenneth Woodhead ...... Refs FAM 100735-0021

Statement - police 55kB 15/01/ 1999

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...... GD19 i ii.i. i.iii ...... Other 0100 Police Statement of John Stephen Grenville re John Henshall Refs ...... 26/03/ Statement - police 130kB 1999

...... [[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[~[[~]~[[

GD21 Other 0100 Police Statement of Irene Henshall re John Henshall ...... Refs 1 26/01/ Statement - police 80kB 1999 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~B22 ;!!iii iiiiiii i i iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiN iiiiiiiiiiiiiii ...... [[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[~[[~[~[[ iiiiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiiiii~ ~ iiiiiiiii~ ~iil i ~ii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii~ ii iig~ ~ iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiii iiiii i~i~iii ii iiii iiii GD23 Other 0100 Police Statement of Lillian Ibbotson: General Refs 1 23/02/ Statement- police 39kB 1999 ::~::~:~:::~:::::~:~:~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~::~::~::~::

GD25 Other 0100 Police Statement of Alan Thomas Oakes re Frank Crompton ...... Refs

Statement - police 48kB 26/01/ 1999 GD~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ==i== i==i i iii6i imi iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii i i i i i i i iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii==i==i==i==i==i==i==i==i==i==i==i==i e ==i==i== FAM 100735-0022

...... i iiiiiiiiiiiiiiiiiiiiiiiiiii iiiiii i i iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii ii "iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii i i i iii iiii GD27 Other 0100 Police Statement of Anne Schofield re Raymond Frank Jones 1 .R..e.[s. 16/03/ Statement - police 35kB 1999 G D 2 ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~:: ::::::::::::::::::::::::::::::::::::::: ~::~::~::~::~ice~::Sta~e::men~::~f::~Barba::ra::~::Sunde::~a::n::d:/:~re~::Keit~1t:/:Ha~r~s~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

Statement - police 44kB 15/01/ 1999 D~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~/~::~ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~~ii~iiiiiiiii~ii~iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~ii~iiBiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii~i~iiiiiiiiiiiii GD30 Other 0100 Police Statement of Dorothy Winterbottom re John Henshall Refs 1 Statement - police 75kB 02/01/ 1999 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~::~ ::~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~: ~::: ::::::::::::::::::::::::::::

...... 19N~

GD32 Other 0100 Untitled ...... Refs Table 286kB

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Form 60kB 01/03/ 1997

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GD33 Other 0300 Untitled Refs 1 Form 59kB 03/03/ 1998 FAM 100735-0023

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GD37 Other 0100 Witness Statement of Amanda Hill ...... Refs 1 17/05/ Statement - witness 46kB 1999 ~t~e~ FAM 100735-0024

Published by The Shipman Inquiry @...C...r.o...w...n....C...o..~..v.r.ig..h..t...2..O...O..!.

TIME EUROPE FEBRUARY 14, 2000 VOL. 155 NO. 6 England’s Angel of Death An energetic family practitioner may be the most prolific murderer in British history By J.F.O. MCALLISTER London

His profession was healing, and many of his patients admired him for his industry and the kindliness that seemed to be reflected in his benign and slightly sad eyes. But behind that caring exterior, Dr. Harold Frederick Shipman was a killer, perhaps the worst in British history. A judge in Preston, 50 km north of Manchester, last week gave him 15 life sentences for the murders, by lethal injection, of 15 women in his care. Prosecutors say they have strong evidence of another 23 killings, and police say he may have slain more than 150 of his patients over several decades.

He got away with murder precisely because he was a doctor and his victims were mostly elderly and single. In Hyde, the plain suburb of Manchester where he worked, Shipman was renowned for his energy and concern and became so popular that even in a solo practice he had 3,100 patients, 9% of the town’s population. He frequently made house calls to check on the sick, to take blood samples or inject antibiotics. But some of them got a different injection: diamorphine, otherwise known as heroin, which doctors normally use to relieve pain. It first put them to sleep and then killed them, usually in about five minutes. Some he killed in his own office, emerging to see other patients while the diamorphine did its work. He covered his tracks by entering bogus ailments on the death certificate, falsifying records to concoct a plausible history of prior illness, discouraging relatives from requesting autopsies and by encouraging cremation.

He killed, apparently, for the thrill of domination he got from causing and observing death. Richard Badcock, a forensic psychiatrist who interviewed him before the trial, says Shipman has a powerful, constant need for control which has taken many forms. Arrogant to other doctors, a domineering husband, greedy for adulation from his patients, he would be "virtually in a state of collapse" when he felt his sense of control threatened-and was never more powerful than when snuffing out the life of someone who trusted him. He was hooked on the painkiller pethidine in the 1970s, which he self-injected to relieve depression, a drug habit he kicked only to become addicted to killing. The death in 1963 of his own doting but demanding mother from cancer, which was eased by morphine, may have been one trigger for his murderous journey. FAM 100735-0025

Whatever the motive, he killed so often that there were some close calls. He poisoned an 81-year-old patient named Maria West in 1995 without realizing that a friend was waiting quietly in the kitchen. He momentarily lost his composure when he came in to wash his hands and encountered her, but gathered himself and announced West’s death. In 1997 a neighbor of Jean Lilley walked over to check on the 58- year-old who was suffering from a cold, and saw Shipman driving away. Inside, the neighbor found Lilley on her couch, freshly dead, her lips turning blue. Typically for Shipman’s victims, Lilley was sitting up and fully clothed. Also that year Shipman visited Kathleen Wagstaff, 81, without a request from her. A friend overheard her say, "Fancy seeing you here," as Shipman arrived; 45 minutes later she was dead.

People became suspicious. John Shaw, a Hyde taxi driver, noticed as early as 1994 that many of his regular customers were dying and that Shipman was their doctor. He began to keep a list. It had reached 23 in 1998 when he went to the police with his fears. An undertaker wondered why Shipman’s practice provided so many corpses. Two nearby doctors worried about the large number of cremation certificates he asked them to countersign. But a cursory review of his death certificates found nothing obviously amiss.

In the end it was greed that halted Shipman’s death machine. He forged the will of Kathleen Grundy, an energetic 81 -year-old former Hyde mayor, leaving her entire estate of $615,000 to him in recognition of "all the care he has given to me and the people of Hyde." But Grundy’s daughter Angela Woodruff is a lawyer. The new, crudely typed will with an unfamiliar signature showed up after her mother’s unexpected death and once she determined that the ostensible witnesses didn’t recall signing it, Woodruff went to the police. Investigators obtained an exhumation order, and tests on Grundy’s body showed fatal levels of diamorphine. Shipman heatedly denied all charges. But he collapsed and then stopped answering questions when the police confronted him with logs from his own computer showing that he had altered his victims’ medical records.

One result of the verdict is deep soul-searching in Britain’s medical profession. Shipman had stockpiled enough diamorphine to murder 1,000 people by picking up prescriptions for patients himself and snitching leftovers from the bedsides of those he murdered. Victims seldom had autopsies because none is required if a physician has seen the patient within two weeks of death. The doctors he asked to authorize cremations did not always examine the bodies or review their case histories. Nor does any agency monitor death rates in medical practices. A government inquiry, set up after the verdict, will recommend how to tighten the supervision of doctors.

Shipman has never confessed to any of the murders. Nor, says psychiatrist Badcock, is he ever likely to, because that would require confronting a terrible shame. So even in jail he will continue to prey on the people of Hyde: keeping hundreds of families in the dark about whether their loved ones died naturally or were random victims of his evil obsession.

The Providers’ Response

MEETING PATIENT NEEDS IN THE COMMUNITY: THE ROLE OF THE PRIMARY HEALTH CARE TEAM Dr Stephen Barclay, Macmillan General Practice Palliative Care Facilitator, Unit of General Practice, Department of Community Medicine, Institute of Public Health, Cambridge In addressing this topic, my role is to talk about the role of the general practitioner (GP) and district nurse (DN) in community palliative care. I have spent the last 11 years as a GP principal, initially in a rural market town setting in Cambridgeshire, and for the last six years in a Cambridge city practice. Where do cancer patients die? The latest available figures for the place of death from the Office for National Statistics are for the year 1992.68.5% died in hospitals, hospices and nursing homes (figures are not currently available for hospice deaths as a separate category.) 25.6% of patients died from cancer in their own home. A further 3.4% died in ’other communal establishments’ (residential homes for the elderly or disabled), and 2.1% died in ’other private houses and other places’ (almost entirely those who FAM 100735-0026

died while staying with a relative). Taking these latter three categories together gives 31.1 % of cancer deaths occurring in what could be loosely described as the patient’s own home: the received wisdom is that 25.6% of deaths occur at home. Certainly most of these 31.1% of deaths would be under the care of the GP and district nurse. But where would terminally ill patients chooses as their place of death? This has been referred to earlier today already: several studies, including those of Townsend and Dunlop have shown that most terminally ill patients would prefer to die at home: not all choose home, but most do so. Further research, especially by Julia Addington-Hall has indicated that most relatives of dying patients would prefer that their loved one die at home. There is evidence that the preferences of both patients and carers for home death diminish as death approaches. Thorpe highlights a paradox that most dying patients (and one could add most lay carers of dying patients) would prefer to remain at home, but most die in institutions. In addition, the work of Seale and Cartwright has shown that most of the last year of life - the 12 months before people die - is spent at home. Thorpe highlights this as a second paradox: that most of the last year of life is spent at home, but most people are admitted to die. So the figures for place of death do not tell us the whole story. Most of the last year of life is spent at home, and thus for most patients the majority of their palliative phase will be spent at home under the care of their GP and district nurse. Furthermore, in a conference such as this it is easy to focus on specialist palliative care services and fail to acknowledge that for most patients the primary health care team has the central role in the provision of palliative and terminal care. This view of the central role of the primary health care team is very much a national policy. The Calman- Hine Report on cancer services describes primary care as ’the focus of cancer care’. The 1992 national report The Principles and Provision of Palliative Care states that ’The primary health care team already provide, and will continue to provide the mainstay of support to patients and families facing terminal illness, even when the act of dying may take place in hospital’. The report went on to recommend that ’the main focus of palliative care services should be the Primary Health Care Team’. But all is not well with palliative care in primary care. Ann Cartwright found in her study of patients in the last year of life that patients consulted their GP about only two thirds of their symptoms; the one third of symptoms which their GPs are not consulted about were sometimes severe and of long standing. Our Health Services Research Group in the Cambridge University Department of Community Medicine has a considerable interest in the role of the primary health care team in palliative care: one of our early studies found that patients and their relatives place considerable value on being at home, in familiar surroundings, and with their trusted professional carers. The project report has a list of useful recommendations for both purchasers and providers, one of which was to plan for a 24-hour intensive home-based nursing service. As part of this study, GPs and district nurses were asked to rate how difficult they found it to control various symptoms. Figure 1 shows the percentages of GPs or district nurses who rated a symptom as difficult to control, * indicating where there was a statistically significant difference between the groups at the level of 0.05. Bowel control, smell, bladder control, breathing and bedsores are the areas that GPs found more difficult to control than did their district nurse colleagues: the district nurses found more difficulty with depression, anxiety, vomiting, constipation, sleeplessness, and pain than did their GP colleagues. Perhaps these differences are not surprising in that the difficult areas could be seen to be largely the domain of the other professional group. What these data do emphasise is the vital importance of teamwork in community palliative care. It is important that not only GPs, but also their district nursing colleagues, should be involved in the control of symptoms: GPs will need to involve their district nurse colleagues early in the course of the patient’s palliative illness. When a patient is identified as entering the palliative phase, district nursing colleagues need to be told as a matter of routine, and to start visiting: later on, when the patient becomes more unwell and needs hands-on nursing care, this will be given by nurses who are already familiar to the patient and lay carer. Familiarity of trusted carers was an important theme which emerged from this study. It is of interest that only 8% of GPs thought that pain control was very or fairly difficult, yet research continues to show poor control of pain in the home. To ensure good control of pain (and other symptoms) there needs to be good communication about the presence of symptoms, good communication about the severity of symptoms, adequate prescribing, and regular reviews. These are all areas that our research group is planning to investigate further in the primary care setting. FAM 100735-0027

How well prepared are GPs for this task of palliative care at home? We have recently undertaken a postal questionnaire study of 450 randomly selected East Anglian GPs: three sequential postal questionnaires were sent, focusing on training in palliative care, pain control and control of other symptoms respectively. One paper has been published, with two more to follow. Figure 2 summarises the data concerning their training: since becoming principals, over 65% of GPs stated that they had received training in the five areas of palliative care we identified (pain control, control of other symptoms, communication skills, bereavement care, and use of syringe drivers); more than 90% reported receiving training in physical symptom control since becoming principals. The two subsequent questionnaires focused more on the control of pain and other symptoms, and were in style much more like an exam paper. One question asked what other non-analgesic drugs they would start when commencing a patient on a strong opioid. In a community setting, one would expect 100% to prescribe a laxative, and 100% to prescribe an anti-emetic (as determined by the literature and a Delphi panel of experts). 54% of our respondents indicated that they would prescribe an anti-emetic, and 50% would prescribe a laxative. This is what the GPs said they would do: what do they actually do in practice? These figures are strikingly similar to Seamark’s study of admissions to the Exeter Hospice, which found percentages of patients on strong opioids who were also taking laxatives or anti-emetics that are very similar to these.

We also asked about the conversion of oral morphine to subcutaneous diamorphine in a syringe driver, Figure 3. What dose of subcutaneous diamorphine over 24 hours would you use to give equivalent analgesia to MST 60 mg bd.?’ 19.4% indicated the strict pharmacological equivalent of 40 mg of diamorphine, and 27.1% the permissible dose range of 41 to 60 mg. 12.5% would ask for advice, which I would see as appropriate: 16.0% significantly underdosed the patient, and 15.6% significantly overdosed (including two GPs who indicated that they would give 240 mg of diamorphine, a sixfold overdose.)

This study and others provide evidence for the need for continuing education for GPs in palliative care: a national project is now underway, funded by Macmillan Cancer Relief, to establish a network of Macmillan GP facilitators, a role that I have in the Cambridge Health District. These data also highlight the need for palliative care specialists to make themselves readily available to advise members of the primary health care team on the control of symptoms that we rarely meet in our generalist community practice, but which are more commonly seen in your specialist work. This century has seen major changes in the places of birth and death in the UK: had I been a family doctor atthe turn of the century, most of my patients would have had their babies at home, and most of my patients would have died at home. Patient choice was discussed this morning, a perspective that is encouraged by the government by the Patient’s Charter. In this century, birth has been medicalised and institutionalised. In obstetrics, there is now a move back into the community for more home births: in an analogous way, I for one hope that the coming years will see a rise in the number of cancer deaths at home, which we know from the literature is where most patients and their lay carers would prefer to be. The early hospice movement focused on specialist inpatient units, and more recently has focused on hospital support teams. I hope that in future years we will not only see the increasing development of community palliative care teams, but that these services will be centred around the primary health care team. I suggest to you that the central professionals in community palliative care are at the present, and will continue to be, the members of the primary health care team.

Copied from British National Formulae Copyright material

Diamorphine (Non-proprietazy) FAM 100735-0028

Tablets, diamorphine hydrochloride 10 mg. Net price 100-tab pack = £12.30. Label: 2 Available from Aurum Inj ection, powder for reconstitution, diamorphine hydrochloride. Net price 5-mg amp = £ 1.18, 10-mg amp = £ 1.36, 30-mg amp = £1.62, 100-mg amp = £4.50, 500-mg amp = £20.68 Available from Berk (Diagesil), CP, Hillcross, Medeva

DIAMORPHINE HYDROCHLORIDE (Heroin Hydrochloride) Indications: see notes above; acute pulmonary oedema Cautions: see under Morphine Salts and notes above; interactions: Appendix 1 (opioid analgesics) Contra-indications: see under Morphine Salts and notes above Side-effects: see under Morphine Salts and notes above Dose: acute pain, by subcutaneous or intramuscular injection, 5 mg repeated every 4 hours if necessary (up to 10 mg for heavier well-muscled patients) By slow intravenous injection, quarter to half corresponding intramuscular dose Myocardial infarction, by slow intravenous injection (1 mg/minute), 5 mg followed by a further 2.5 - 5 mg if necessary; elderly or frail patients, reduce dose by half Acute pulmonary oedema, by slow intravenous injection (1 mg/minute) 2.5 - 5 mg Chronic pain, by mouth or by subcutaneous or intramuscular injection, 5 - 10 mg regularly every 4 hours; dose may be increased according to needs; intramuscular dose should be approx, half corresponding oral dose, and approx, one third corresponding oral morphine dose--see also Prescribing in Palliative Care; by subcutaneous infusion (using syringe driver), see Prescribing in Palliative Care, Syringe Drivers

MORPHINE SALTS Indications: see notes above and under Dose; acute diarrhoea (section 1.4.2); cough in terminal care (section 3.9.1) Cautions: hypotension, hypothyroidism, asthma (avoid during attack) and decreased respiratory reserve, prostatic hypertrophy; pregnancy and breast-feeding; may precipitate coma in hepatic impairment (reduce dose or avoid but many such patients tolerate morphine well); reduce dose or avoid in renal impairment (see also Appendix 3), elderly and debilitated (reduce dose); convulsive disorders, dependence (severe wifl~drawal symptoms if wifl~drawn abruptly); use of cough suppressants containing opioid analgesics not generally recommended in children and should be avoided altogether in those under at least 1 year; interactions: Appendix 1 (opioid analgesics) PALLIATIVE CARE. In fl~e control of pain in terminal illness these cautions should not necessarily be a deterrent to the use of opioid analgesics Contra-indications: avoid in acute respiratory depression, acute alcoholism and where risk of paralytic ileus; also avoid in raised intracranial pressure or head injury (in addition to interfering wifl~ respiration, affect pupillary responses vital for neurological assessment); avoid inj ection in phaeochromocytoma (risk of pressor response to histamine release) Side-effects: nausea and vomiting (particularly in initial stages), constipation, and drowsiness; larger doses produce respiratory depression and hypotension; other side-effects include difficulty with micturition, ureteric or biliary spasm, dry mouth, sweating, headache, facial flushing, vertigo, bradycazdia, tachycardia, palpitations, postural hypotension, hypothermia, hallucinations, dysphoria, mood changes, dependence, miosis, decreased libido or potency, rashes, urticaria and pruritus; overdosage: see Emergency Treatment of Poisoning; for reversal of opioid- induced respiratory depression, see section 15.1.7. Dose: acute pain, by subcutaneous injection (not suitable for oedematous patients) or by intramuscular injection, 10 mg every 4 hours if necessary (15 mg for heavier well-muscled patients); CHILD up to 1 month 150 micrograms&g, 1 - 12 months 200 micrograms/kg, 1 - 5 years 2.5 - 5 mg, 6 - 12 years 5 - 10 mg By slow intravenous injection, quarter to half corresponding intramuscular dose Premedication, by subcutaneous or intramuscular injection, up to 10 mg 60 - 90 minutes before operation; CHILD, by intramuscular injection, 150 micrograms/kg Postoperative pain, by subcutaneous or im3:amuscular inj ection, 10 mg every 2 - 4 hours if necessary (15 mg for heavier well-muscled patients); CHILD up to 1 month 150 micrograms/kg, 1 - 12 monfl~s 200 micrograms&g, 1 - 5 years 2.5 - 5 mg, 6 - 12 years 5 - 10 mg FAM 100735-0029

Note. In the postoperative period, the patient should be closely monitored for pain relief as well as for side-effects especially respiratory depression Patient controlled analgesia (PCA), consult hospital protocols Myocardial infarction, by slow intravenous injection (2 mg/minute), 10 mg followed by a further 5 - 10 mg if necessary; elderly or frail patients, reduce dose by half Acute pulmonary oedema, by slow intravenous inj ection (2 mg/minute) 5 - 10 mg Chronic pain, by mouth or by subcutaneous injection (not suitable for oedematous patients) or by intramuscular injection, 5 - 20 mg regularly every 4 hours; dose may be increased according to needs; oral dose should be approx. double corresponding intramuscular dose and approximately triple corresponding intramuscular diamorphine dose (see also Prescribing in Palliative Care); by rectum, as suppositories, 15 - 30 mg regularly every 4 hours Note. The doses stated above refer equally to morphine hydrochloride, sulphate, and taztrate; see Modified release, MORPHINE SALTS for doses of modified-release preparations.

MIXING AND COMPATIBILITY. The general principle that injections should be given into separate sites (and should not be mixed) does not apply to the use of syringe drivers in palliative care. Provided that there is evidence of compatibility, selected injections can be mixed in syringe drivers. Not all types of medication can be used in a subcutaneous infusion. In particular, chlorpromazine, prochlorperazine and diazepam are cont3:a-indicated as they cause skin reactions at the injection site; to a lesser extent cyclizine and levomepromazine (methot3:imeprazine) may also sometimes cause local irritation. In theory injections dissolved in water for injections are more likely to be associated with pain (possibly owing to their hypotonicity). The use of physiological saline (sodium chloride 0.9%) however increases the likelihood of precipitation when more than one drug is used; moreover subcutaneous infusion rates are so slow (0.1 - 0.3 mL/hour) that pain is not usually a problem when water is used as a diluent. Diamorphine can be given by subcutaneous infusion in a strength of up to 250 mg/mL; up to a strength of 40 mg/mL either water for injections or physiological saline (sodium chloride 0.9%) is a suitable diluent--above that strength only water for injections is used (to avoid precipitation). The following can be mixed with diamorphine:

Cyclizinel Dexamethasone2 Haloperidol3 Hyoscine butylbromide Hyoscine hydrobromide Levomepromazine Metoclopramide4 Midazolam Subcutaneous infusion solution should be monitored regularly both to check for precipitation (and discoloration) and to ensure fl~at fl~e infusion is running at the correct rate.

1. Cyclizine may precipitate at concentrations above 10 mg/mL or in the presence of physiological saline or as the concentration of diamorphine relative to cyclizine increases; mixtures of diamorphine and cyclizine are also liable to precipitate after 24 hours. 2. Special care is needed to avoid precipitation of dexamethasone when preparing. 3. Mixtures of haloperidol and diamorphine are liable to precipitate after 24 hours ifhaloperidol concentration is above 2 mg/mL. 4. Under some conditions metoclopramide may become discoloured; such solutions should be discarded.

Routes of administration The oral route is preferred whenever possible as it is convenient and cost effective. Possible indications for oilier routes include: severe dysphagia, FAM 100735-0030

intractable nausea and vomiting, head and neck cancer, intestinal obstruction, comatose or semiconscious patient, parenteral administration required for rapid onset in acute pain. The rectal route may provide a suitable alternative for some patients. Morphine suppositories are available, or oxycodone suppositories (an unlicensed preparation) caw be obtained as a ’special’.8 A variety of NSAIDs and axlti- emetics are also available in suppository form. If parenteral administration is necessary, subcutaxleous injection is preferred over flae intramuscular route as it is less painful. Intravenous administration may be necessary in patients with oedema, coagulation disorders, poor peripheral circulation, or those who develop erythema at the site of injection. It may also be preferred in those who have continuous intravenous access through an indwelling cannula. 10 Diamorphine is the opioid of choice as it is more soluble than morphine and can be given in a much smaller volume. The dose of diamorphine by inj ection is approximately one-quarter to one-third of that of oral morphine.8 Continuous treatment with parenteral diamorphine caw be given using a battery-driven syringe driver. This has the advantage of avoiding repeated injections. Several other drugs, including some axlti-emetics and sedatives can be mixed in the same syringe. Details on drug compatibility are given in the BNF in the section entitled ’Prescribing in Palliative Care’. Drawbacks of flais method of administration include injection site reactions, and a lack of flexibility to vary the dose during the day to treat breakthrough pain. Some devices have a facility to provide patient controlled rescue doses, although the usefulness of this may be limited e.g. the concentration of drug in the syringe may not allow an adequate dose to be given by this meflaod. If this is not available or is unsuitable, additional doses of analgesic need to be prescribed. Occasionally, more invasive drug delivery systems are used. The epidural and intrathecal routes are increasingly being used in patients whose pain is not controlled by other means, although flae precise indications for these systems are not established. The main advantage of the spinal route is a lower incidence of opioid adverse effects.5 Recently, a txansdermal formulation of flae high potency opioid fentanyl has been introduced. Published data on the efficacy of this formulation in patients wifla cancer pain are limited. Open studies suggest that it is effective and well tolerated, 14,15 but its place in therapy has yet to be established. 10 As wifla other prolonged action formulations, a rapid-onset analgesic should be prescribed for breakthrough pain. It is not suitable for patients whose analgesic requirements are changing rapidly.

Misuse of Drugs Act The Misuse of Drugs Act, 1971 prohibits certain activities in relation to ’Controlled Drugs’, in particular their manufacture, supply, and possession. The penalties applicable to offences involving the different drugs are graded broadly according to flae harmfulness attributable to a drug when it is misused and for flais purpose the drugs are defined in the following three classes:

Class A includes: alfentanil, cocaine, dextxomoramide, diamorphine (heroin), dipipanone, lysergide (LSD), meflaadone, methylenedioxymethamfetamine (MDMA, ’ecstasy’), morphine, opium, pethidine, phencyclidine, and class B substances when prepared for injection Class B includes: oral amphetamines, barbiturates, cannabis, cannabis resin, codeine, ethylmorphine, gluteflaimide, pentazocine, phenmetxazine, and pholcodine Class C includes: certain drugs related to flae amphetamines such as benzfetamine and chlorphentermine, buprenorphine, dieflaylpropion, mazindol, meprobamate, pemoline, pipradrol, most benzodiazepines, androgenic and anabolic steroids, clenbuterol, chorionic gonadotxophin (HCG), non-humaxl chorionic gonadotrophin, somatotyopin, somatxem, and somatropin

The Misuse of Drugs Regulations 1985 define the classes of person who are authorised to supply and possess controlled drugs while acting in flaeir professional capacities and lay down flae conditions under which these activities may be carried out. In flae regulations drugs are divided into five schedules each specifying the requirements governing such activities as import, export, production, supply, possession, prescribing, and record keeping which apply to them. FAM 100735-0031

Schedule 1 includes drugs such as cannabis and lysergide which are not used medicinally. Possession and supply are prohibited except in accordance with Home Office authority. Schedule 2 includes drugs such as diamorphine (heroin), morphine, pefl~idine, secobazbital, glutethimide, amfetamine, and cocaine and are subject to fl~e full controlled drug requirements relating to prescriptions, safe custody (except for secobazbital), the need to keep registers, etc. (unless exempted in schedule 5). Schedule 3 includes the barbiturates (except secobazbital, now schedule 2), buprenorphine, diethylpropion, flunitrazepam, mazindol, meprobamate, pentazocine, phentermine, and temazepam. They are subject to the special prescription requirements (except for phenobarbital and temazepam, see Prescriptions under Controlled Drugs and Drug Dependence) but not to the safe custody requirements (except for buprenorphine, diefl~ylpropion, flunitrazepam, and temazepam) nor to the need to keep registers (although fl~ere are requirements for the retention of invoices for 2 years). Schedule 4 includes in Part II 33 benzodiazepines (flunitrazepam and temazepam are now in schedule 3) and pemoline which are subject to minimal control. Part I includes androgenic and anabolic steroids, clenbuterol, chorionic gonadotrophin (HCG), non-human chorionic gonadotrophin, somatotropin, somat3:em, and somat3:opin. Controlled drug prescription requirements do not apply and Schedule 4 Controlled Drugs are not subject to safe custody requirements. Schedule 5 includes those preparations which, because of their strength, are exempt from virtually all Controlled Drug requirements other than retention of invoices for two years.

Palliative care Diamorphine and mefl~adone have been used to control distressing cough in terminal lung cancer although morphine is now preferred (see Prescribing in Palliative Care). In oilier circumstances they are com3:a-indicated because they induce sputum retention and ventilatory failure as well as causing opioid dependence. Methadone linctus should be avoided because it has a long duration of action and tends to accumulate.

NAUSEA AND VOMITING. Haloperidol is given in a subcutaneous infusion dose of 2.5 - 10 mg/24 hours. Levomepromazine (mefl~otrimeprazine) causes sedation in about 50% of patients; it is given in a subcutaneous infusion dose of 25 - 200 mg/24 hours, alfl~ough lower doses of 5 - 25 mg/24 hours may be effective with less sedation. Cyclizine is particularly liable to precipitate if mixed with diamorphine or other drugs (see under Mixing and Compatibility, below); it is given in a subcutaneous infusion dose of 150 mg/24 hours. Metoclopramide may cause skin reactions; it is given in a subcutaneous infusion dose of 30 - 100 mg/24 hours. Oct3:eotide (section 8.3.4.3), which stimulates water and electrolyte absorption and inhibits water secretion in the small bowel, can be used by subcutaneous infusion, in a dose of 300 - 600 micrograms/24 hours to reduce intestinal secretions and vomiting.

Pain Analgesics are more effective in preventing pain than in the relief of established pain; it is important that they are given regularly. The non-opioid analgesics aspirin or pazacetamol given regularly will often make the use of opioids unnecessary. Aspirin (or other NSAIDs if preferred) may also com3:ol the pain of bone secondaries; naproxen, flurbiprofen, and indometacin (section 10.1.1) are valuable and if necessary can be given rectally. Radiofl~erapy, bisphosphonates (section 6.6.2) and radioactive isotopes of strontium (Metast3:on available from Amersham) may also be useful for pain due to bone metastases. An opioid such as codeine or dextropropoxyphene, alone or in combination with a non-opioid analgesic at adequate dosage, may be helpful in the control of moderate pain if non-opioids alone are not sufficient. If these preparations FAM 100735-0032

are not controlling the pain, morphine is the most useful opioid analgesic. Alternatives to morphine are hydromorphone, oxycodone (section 4.7.2) and tyansdermal fentanyl (see below and section 4.7.2).

Equivalent single doses of strong analgesics These equivalences are intended only as an approximate guide; patients should be carefully monitored after any change in medication and dose titration may be required

Morphine salts (oral) 10 mg equivalent to Diamorphine hydrochloride (parenteral) 3 mg equivalent to Hydromorphone hydrochloride 1.3 mg equivalent to Oxycodone 5 mg

SUMMARY Pain control is an important part of palliative care. The aim is to keep patients pain free with minimal side-effects from medication. The analgesic regimen should be tailored to meet the needs of the patient. A stepwise approach based on the concept of an ’analgesic ladder’ is widely promoted. The first ’step’ involves the use of non-opioid analgesics, e.g. pazacetamol and non-steroidal anti-inflammatory drugs. If these do not control pain, one of the opioids suitable for mild to moderate pain is added - step 2. At step 3, opioids suitable for severe pain are used. Morphine is the preferred oral opioid at step 3. If doses are carefully tityated, and side-effects anticipated and managed appropriately, there are few problems with the use of this drug. Many of the concerns about morphine, e.g. the fear of dependence, are unfounded. The oral route of administration is preferred as it is convenient, safe, and effective for most patients. Doses should be given regularly to prevent pain, rather than having to relieve it after it has occurred. Long-acting formulations may be useful, but must be supplemented with a rapidly-acting preparation for breakthrough pain. The rectal, subcutaneous and intravenous routes provide alternatives when oral administration is not possible. Intramuscular injection should be avoided. Its high solubility makes diamorphine the opioid of choice for parenteral use. A transdermal opioid is also available, but its place in therapy is not yet established. Various adjuvant analgesics are used to treat types of pain which respond poorly or partially to conventional analgesics. These may be imyoduced at any stage.