Part 3 - Ralph Winstanley - FACTS about his death - 18Apr2004

Click for A Full Index - but stay on this page if you want to read the main facts

Table of FACTS in respect of Ralph Winstanley’s death
23Apr2004 - plus numerous supporting document abstracts
Third part - 18Apr2004

18Apr2004 - early Sunday morning 03.00
Nina Clayton telephoned Linda Kirby – yet again - to say that her father Ralph Winstanley was dying. Linda went across to Grange Farm, arriving at 4am
Affidavit abstract - Linda Kirby - No 34a
Affidavit abstract - Charlotte Peters Rock - No 34b

18Apr2004 - 06.18
Nina Clayton telephoned the on-call doctor service
Stating that Ralph Winstanley was ‘terminally ill, getting worse, not mobile stopped eating.’
The note was also made:
‘Wife very concerned – needing help’

FACT: About this contact Dr Kevin Lee states: ‘I was on duty at DDS on 18th April 2004 when Mrs Winstanley rang regarding her husband. The time was 06.18.
I replied at 06.40 & heard from Mrs Winstanley that her husband who was suffering from multiple terminal pathologies including Chronic Leukaemia, heart failure, stomach nodules & low protein had been seen the previous Friday by Dr David Brown his GP.
Dr Brown had given Mr Winstanley a terminal prognosis.’

ADASTRA Consultation note - Dr Kevin Lee - No 35
Danum Doctors - Dr Kevin Lee - Letter dated 18May2004 - page 1 - No 36a
Danum Doctors - Dr Kevin Lee - Letter dated 18May2004 - page 2 - No 36b
NOTE WELL: ‘multiple terminal pathologies’ and ‘terminal prognosis’.
But no documentary confirmation

NOTE WELL: Terminal care prescribed, patient not seen by any doctor

FACT: Dr Kevin Lee’s letter also states:
‘Mrs Winstanley reported that Mr Winstanley was distressed & had not slept well during the night.’
Danum Doctors - Dr Kevin Lee - Letter dated 18May2004 - page 1 - No 36a
Danum Doctors - Dr Kevin Lee - Letter dated 18May2004 - page 2 - No 36b

FACT: On the basis of this call, with no medical confirmation of anything which he was told, Dr Kevin Lee seems to have thought it reasonable, without ever seeing the patient – to prescribe Terminal Care for the first time. Letter dated 18May2004
Danum Doctors - Dr Kevin Lee - Letter dated 18May2004 - page 1 - No 36a
Danum Doctors - Dr Kevin Lee - Letter dated 18May2004 - page 2 - No 36b

18Apr2004 - 08.45
The first Nursing Sister to visit – sent by Dr Kevin Lee of Danum Doctors, who never meets Ralph Winstanley - states nothing about observing Ralph Winstanley being in any pain. She only states that he is ‘settled’. However, she does state that Mrs Winstanley tells her that:
‘her husband has settled a little but remains restless’.
Her notes make it obvious that she does not observe this for herself
Community Intervention Team Office Notes - Sister S Zadrozny - 37a
NOTE WELL: Not observed to be in pain

The Community Intervention Team Dependency Scale, which must have been filled in for the benefit of other nurses, on 18 Apr2004 – when CIT nurses first saw him – states that: (in a scoring system of 1-5)
‘Personal Care – Dependent’ (5)
‘Feeding – Medium – poor appetite at the moment’(3)
‘Continence – High – catheterised’(4)
‘Mobility – Low – uses a walking stick’(2)
Nursing – medium – frequent visits (3)
Psychological health – Independent – self sufficient’(1)
‘Total scoring – 18 – medium’
which is interesting – to say the least. The total score is only 18. Total dependency – on this scale – comes in at 25+
Community Intervention Team - Dependency Scale - 18Apr2004 - No 48
NOTE WELL: No mention of patient being unable to take food or drink – or being unable to walk or bedfast

FACT: At this point on 18Apr2004, Ralph Winstanley’s psychological health is stated to be ‘independent’ and ‘self-sufficient’.
In that case, why did none of the nurses listen when he stated – on numerous occasions, over those two days, that he had no pain?Community Intervention
Community Intervention Team - Dependency Scale - 18Apr2004 - No 48

18Apr2004 - 18.37
Nina Clayton telephoned the Twilight Nurses, who contacted Danum Doctors again, stating ‘c/o started on syringe driver today. Aggitated. Trying to pull catheter out.’
Danum Doctors - ADASTRA Consultation note - Dr Kevin Lee - No 38

About this contact, Dr Kevin Lee states:
‘Later the same day at 18.37 a further call regarding Mr Winstanley was received by DDS. The call was from the Twilight Nurses who had been contacted by Mr Winstanley’s family saying that he was agitated & had been trying to pull his indwelling catheter out.. Dr Bundy arranged for a prescription for Midazolam & Haloperidol to be collected.’
Danum Doctors - Dr Kevin Lee - Letter dated 18May2004 - page 2 - No 36b

Dr Kevin Lee also states:
‘..so I spoke with the nurses as I was already familiar with Mr Winstanley’s case from earlier in the day.’
Danum Doctors - Dr Kevin Lee - Letter dated 18May2004 - page 2 - No 36b

From the fact that he stated that he was ‘familiar’ with a patient whom he had never met, and whom no-one had observed to be in any pain, Dr Kevin Lee was happy to increase the number of drugs going into Ralph Winstanley, in this Terminal Care, and to order a second syringe driver.
Danum Doctors - Dr Kevin Lee - Letter dated 18May2004 - page 2 - No 36b
NOTE WELL: Level of ‘terminal care’ increased – but patient has ‘no pain’

FACT: During the whole of that day and the following day (19Apr2004), Ralph Winstanley kept stating to the nurse that he was not in any pain.
Letter dated 18 May 2004
4th Affidavit, abstract - 18Apr2004 - Charlotte Peters Rock - No34b

18Apr2004 - 23.45
RGN Shannon, who claims – erroneously – that she set up a second syringe-driver at this time also states, in the Community Intervention Team Office Notes: ‘Ralph settled throughout the procedure’
She makes no mention of observing him to be at all unsettled – or in any pain
Community Intervention Team Office Notes - RGN B Shannon - No 37a
Community Intervention Team Office Notes - RGN B Shannon - No 37b
NOTE WELL: No pain observed.

18Apr2004 - 23.45
NOTE WELL: RGN B Shannon, also records in the Nursing Notes, that a second syringe-driver was set up at this visit.

Nursing Notes - RGN B Shannon & C Morris - No 39

Because of other entries in the Clinical Notes File, and the Syringe Driver Form, which disprove this statement, this entry shows that the Clinical Notes File was tampered with, at this point after Ralph Winstanley had died.
Nursing Notes - RGN PA Jones - No 46a
Nursing Notes - RGN PA Jones - No 46b
Nursing Notes - Syringe Driver Form - page 1 - No 41a
NOTE WELL: First 4 entries which show only 1 syringe driver in situ until 17.00 on 19Apr2004

FACT: There is a solitary entry on an otherwise empty Infusion Check Chart, which also claims that a second syringe-driver was in place at 23.45 on 18/04/2004
Infusion Check Chart - RGN B Shannon - No 40
(This syringe is stated as having 48mm of Midazolam. When first set up, this is not possible, since some of the fluid would be in the tube and in the needle itself, so the more likely amount in the syringe would be 44mm – had one been set up at all.
Entries in the Syringe Driver Form show this pattern. Each time the syringe driver was initially set up or repositioned - it shows less than 48mm. – usually 44mm)

18Apr2004 - 23.45
The Syringe-driver Form shows quite clearly that only one syringe driver was in place at 23.45 on 18/04/2004 – and that the amount of drug followed the time-to-amount band down from
18Apr2004 - 13.20 – 42mm – first filled – R leg
18Apr2004 - 21.00 – 28 mm – checked – Right leg
18Apr2004 - 23.45 – 20mm – checked – Right leg
19Apr2004 - 09.10 – 45mm – checked – Right side chest
19Apr2004 - 17.00 – 44mm – first set up - Left upper arm
19Apr2004 - 17.00 – 44mm – checked – Right upper arm
This shows that nurses check at each visit, whatever syringe drivers are in place –and record the amount of drug remaining.
(The syringe-driver takes 48mm when full. It releases fluid at the rate of 2mm per hour. So each re-fill can last for 24 hours. Newly set up syringe drivers show less in the syringe because some of the fluid is used to fill the tube and the needle.)
Nursing Notes - Syringe Driver Form - page 1 - No 41a

Syringe-driver Form - C Walker, K Watts, B Shannon, PA Jones, J Marshall, J Marshall - No 41b

18Apr2004 - 23.45
There was no second syringe-driver available on that night, so it could not have been set up on that visit.

FACT: Ralph Winstanley’s daughter notes, in her Affidavit (presented to Coroner and Police on 27Apr2004 – before she again saw the Clinical Notes File) that “I was surprised to be told that he now had a second ‘driver’ in place on his left leg.” She had been absent from 09.30am on 19Apr2004 and had returned to the house just after midnight (00.30) on 19/20Apr2004 when she first saw it.
Affidavit abstract - Charlotte Peters Rock - No 42

18Apr2004 - 23.45
Ralph Winstanley’s elder daughter, Charlotte, remembers hearing Nurse Shannon, speaking on the phone, in the kitchen – at her 23.45 visit – 18Apr2004 - as she requested another syringe-driver by telephone and was told that none was available.

FACT: on 19Apr2004 - Ralph Winstanley’s younger daughter Linda notes in her Affidavit “With one syringe driver already in his thigh when I left to see my mother around midday, I was only away a couple of hours at the most, but dad had another syringe driver in his other thigh when I arrived back.”
Affidavit abstract - Linda Kirby - No 42a

FACT: She also notes: “Even with 2 syringe drivers in his thighs, Dad was still getting in and out of bed, standing and walking to his chair at the bottom of the bed, sitting for a while and getting up himself and walking back to his bed.”
Verbal only


Danum Doctors Pharmacy Record shows that only one dose of Midazolam was prescribed on Sunday 18 April. That is enough for only one injection. It is not enough to put into a second syringe-driver. No-one else was prescribing on 18 April, since it was a weekend. No doctor from Ralph Winstanley’s GP Practice saw him until lunchtime on Monday 19 April
Pharmacy Record in respect of Danum Doctors prescribing - Weldricks, East Laith Gate - No 43

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Protest songs and poems - coming shortly

  • A Full Index
  • Abide With Me (mine)
  • Dead An Buried? Ardly!
  • Director of Public Health - Dr Tony Baxter
  • If - (not by Rudyard Kipling)
  • Jayne Brown - The Cover-Up Woman
  • Practice - Field Road Made
  • Quack Quack Dr Lee
  • St John's Hospice - My Father Was Not Dying
  • Thanksgivin? Thanksgivin? Ah'll be Waitin On
  • The NHS/PCT Thinks You Should Go
  • The Palliative Gillian
  • The Power behind the Patient Dr Brown

Who was Ralph Winstanley?

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