Morphine played role in patients' deaths

A CORONER has called for a review of GPs' systems of working after finding that high doses of morphine administered by an elderly doctor contributed to the deaths of three patients.

Durham Coroner Andrew Tweddle said he would be writing to the medical authorities to highlight issues raised during the inquests into three men who were treated by Dr Howard Martin.

The 75-year-old GP was cleared of murdering Frank Moss, 59, Harry Gittins, 74, and Stanley Weldon, 74, with overdoses of morphine after a trial at Teesside Crown Court in December 2005.

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All three men were patients of Dr Martin when he was a partner at the Jubilee Medical Group, which had surgeries in Newton Aycliffe, Shildon and Eldon, all in County Durham.

Mr Tweddle said: "It has already been determined that Dr Martin did not intend to kill Mr Weldon, Mr Moss or Mr Gittins and nothing in this verdict should be construed in any way to undermine that fact.

"Dr Martin has been described to me as an old-fashioned, traditional general practitioner, one who placed great store on his close personal relationship with his patients.

"However, such old fashioned and traditional values should not have extended to a course of treatment which was described as 'risky' or 'antiquated'.

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"His patients would have expected treatment that was in line with the accepted medical practice of the day, amended to the circumstances as necessary by Dr Martin, in keeping with his personal approach to the care of the terminally ill.

"The public should have complete faith in the GPs as they place their lives in their hands.

"I think it is appropriate for those who have power to influence the way GPs work and operate to consider once again what further changes are necessary, if any, in an endeavour to attempt to avoid similar fatalities in the future.

"Accordingly, I propose to write a letter to the relevant authorities, in general terms, urging them to review their systems once again, in the light of the evidence given at these inquests."

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After Dr Martin's acquittal, Mr Tweddle had decided not to hold an inquiry into the deaths, saying a thorough investigation had already taken place and he could not force the GP to give evidence.

But in November last year, a High Court judge overruled his decision and ordered an inquest into the death of cancer patient Mr Moss following a legal challenge by his daughter, Allison.

During the month-long hearing at Chester-le-Street Magistrates' Court, Dr Martin did give evidence but declined to answer several questions following legal advice.

Mr Tweddle said: "It is unfortunate that in 2000 there were a lack of options available within the NHS to deal with GPs about whom concerns had been raised.

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"It is recognised that these events took place several years ago and there has been since that time a number of system changes designed to improve both patient safety and GP performance.

"A number of such reforms have been as a result of the report of Dame Janet Smith in the Shipman inquiry. Not all recommendations have yet been implemented.

"Dame Janet Smith had available to her considerable evidence and resources to enable her to make considered recommendations in her reports. I have neither.

"I am not able to determine whether the changes yet implemented are sufficient and adequate."

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Mr Tweddle recorded a verdict of misadventure on Mr Gittins and open verdicts on Mr Wheldon and Mr Moss.

A spokeswoman for the Medical Defence Union, which represents Dr

Martin, said he did not wish to comment on the findings.

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