In October 2012, journalistic initiative elicited some horrific facts about what has come to be known in the UK as the Death Pathway (or Liverpool Care Pathway). Until then, many medical professionals had waxed lyrical about Britain’s sedation-dehydration regime. International conferences were run extolling the programme. Medical staff warmly congratulated one another on its use. It looked as though the Pathway was destined for global implementation. Although thousands of families had experienced enormous grief over its use, little attention was paid to them. Legal and medical professionals who warned that death cannot always be diagnosed with any certainty and that placing patients on the sedation-dehydration regimen could all too easily prove self-fulfilling were dismissed as crackpots. Indeed, I was among them. For years I had warned of the political, financial and medical interests that there are in institutionalising medical homicide whether by passive or active means.
That October, thanks to Freedom of Information Act requests performed by the journalist, Simon Caldwell, certain grotesque facts emerged. We already knew that in 2008 the Pathway had become a national strategy. The unspoken reality was that cash payments to Hospital Trusts and other institutions had incentivised the strategy on a grand scale. Managerial targets identified institutions and staff as failing if they did not get sufficient numbers of patients onto the Pathway. What we did not know, and what the Caldwell figures revealed in no uncertain terms, was just how successful this appalling strategy had become. Steve Doughty of the Daily Mail revealed how the incentivisation operated by way of CQUIN payments to hospital Trusts. (‘Hospitals bribed to put patients on the pathway to death ‘Daily Mail 25 October 2012) CQUIN payments to one hospital trust connected to the Liverpool Care Pathway almost halved after failing to reach targets. An article in the Daily Telegraph made the perverse figures showing a staggering implementation of the lethal strategy all too plain. Hospital trusts were asked how many people had died on the LCP over the past three years and how much money received in that period was attached to goals involving it. 61 of the trusts that responded agreed that they did use the Pathway. This translated, so it was reported, to 85% of the total. Further of those, 62% revealed that they had accepted or were expecting to receive payments for meeting targets set in keeping with the national strategy. The rest said that they had applied the Pathway without any cash incentive. Central Manchester University Hospitals, it was said had received £81,000 in 2010 for meeting LCP related targets. The proportion of patients whose deaths were expected and had been placed on the Pathway more than doubled to 87.7 per cent in just that one year. The Heatherwood and Wexham Park Hospitals Trust in Berkshire received more than £1 million over two years for meeting LCP targets. Goals set included carrying out an audit of the number of deaths of patients on the LCP as well as, so it was reported, having a “meaningful conversation” with the patient themselves. This Trust did not set any specific goal for the number of deaths to be achieved. John Bingham wrote:
Bradford teaching Hospitals, which qualified for CQUIN payments of more than £490,000 in the last two years, has seen the number of patients dying on the pathway more than double to 51 per cent over the last three years. In Birmingham the Heart of England NHS Foundation Trust disclosed that 38 per cent of patient deaths occurred on the LCP in 2010 and 27 per cent in 2011. It received a CQUIN payment of £603,886 in the financial year 2010-11 alone. A handful of trusts openly spoke of either hitting or missing targets connected to the LCP in their responses.” (John, Bingham, NHS millions for controversial care pathway 31 October 2012.)
In response to the figures and the ensuing public and parliamentary outcry, a review was ordered. In July 2013 the independent review of the Liverpool Care Pathway (LCP) published its report ’More Care, Less Pathway’. This recognised that in many hospitals, hospices and care homes, abuse and mistreatment was endemic. It is a feature of human vice that induced death is a natural method for concealing abuse. It is also an unfortunate feature of life that workers, when programmes are rolled that set targets that bear on their very employment, will do what is necessary to retain their post.
The review panel recommended that the use of the LCP be phased out within 6-12 months.
In response to the report’s 44 recommendations, a self-styled “Leadership Alliance” for the Care of Dying People (LACDP) was set up to lead and provide a focus for improving the care for these people and their families. The Alliance is chaired by Dr Bee Wee, National Clinical Director for End of Life Care at NHS England. Bee Wee, however, is a longstanding defender of the self-fulfilling Death Pathway. She continues to deny the shocking implications of the Caldwell figures and October revelations. Indeed, thousands of medics and nurses continue to demonstrate a singular lack of interest in the Caldwell figures or the Neuberger Review, merely insisting ever more vociferously that the Pathway, whether or not it is being routinely misapplied to non-dying patients, remains the best way for a patient to die. Neither the British Medical Association not the British Medical Journal has addressed the question of the hugely increased numbers of people dying on the Pathway after the 2008 national incentivised strategy. One can only speculate as to why, in the face of the facts and figures, they continue to close their eyes to the problem.
An alliance of families opposing the the Pathway, represented by Denise Charlesworth Smith, has expressed no confidence in Bee Wee and has called for her resignation as Alliance Leader. Importantly, their concerns have nowhere received attention. They are not represented on the Alliance. Legal and medical professionals who have long warned of the Pathway’s lethal implications are not parties to the chummy, new proceedings.
Again, training programmes for possible new end-of-life care regimes are now being rolled out around the country. The Pathway’s longstanding opponents have been systematically excluded and, surprise, surprise, the grieving families are nowhere represented.
Given that membership of the Leadership Alliance is reserved for those statutory organisations likely to roll out any new programme, and given that its petite and pleasant but wilfully ignorant leader remains a critic of the ‘negative publicity’ that has upset the Death Pathway applecart, it looks as though whatever emerges from the Leadership Alliance is destined to be a fait accompli, and one, more than likely, worse than its predecessor. The lethal blindness of medical professionals who continue to deny the significance of the Caldwell figures and the Neuberger Review remains part of the problem facing vulnerable people in hospitals, hospitals and care homes in the United Kingdom. The homicidal culture highlighted both by the figures and the Review has by no means disappeared.
On active and passive euthanasia only, please see:
LAING Jacqueline A. (2013) “Normalising a Homicidal Culture of Healthcare” Solicitors Journal, 157 no 29 23-07-13
LAING Jacqueline A. (2013) “Managerialising Death” Law Gazette Online (http://www.lawgazette.co.uk/68831.article)
LAING Jacqueline A. and CHARLESWORTH Phil. (2013) “Institutional Human Rights Abuse” New Law Journal 7570 (2013) 25-7-13
LAING Jacqueline A. (2013) Infanticide: A Reply to Giubilini and Minerva 39 Journal of Medical Ethics 336-340.
LAING Jacqueline A. (2012) “Incentivising Death” Solicitors Journal, 157, 9
LAING Jacqueline A. (2012) “A Lethal Power” New Law Journal, 162, 7438, p 1444
LAING Jacqueline A. (2012) “Institutionalising Murder” Halsbury’s Law Exchange http://www.halsburyslawexchange.co.uk/assisted-suicide-institutionalised-murder/
LAING Jacqueline A. (2012) “Not In My Name” 162 New Law Journal (2012) 81
LAING Jacqueline A. (2008) Information Technology and Biometrics Databases: Eugenics and Other Threats to Disability Rights, Journal of Legal Technology Risk Management, 3-26
LAING Jacqueline A. (2010) On the Wrong Track Solicitors Journal 154 Solicitors Journal 2
LAING Jacqueline A. (2004). Mental Capacity Bill – a threat to the vulnerable. New Law Journal, 154, 1165.
LAING Jacqueline A. (2004). Disabled need our protection. Law Society Gazette, 101, 12.
LAING Jacqueline A. (2005). The right to live: Reply to the Chief Executive of the Law Society. Law Society Gazette, 102, 11
LAING Jacqueline A. (2005). The Mental Capacity Bill 2004: Human rights concerns. Family Law Journal, 35:137-143
LAING Jacqueline A. (2002). Vegetative state – the untold story. New Law Journal, 152, 1272.
LAING Jacqueline A. (1996). Innocence and Consequentialism: Inconsistency, Equivocation and Contradiction in the Philosophy of Peter Singer. In D. S. Oderberg, & J. A. Laing (Eds.) Human lives: Critical essays on consequentialist bioethics (pp. 196–225). London: Macmillan.
LAING Jacqueline A. and Oderberg David S (Eds.) Human Lives: Critical Essays on Consequentialist Bioethics (pp. 196–225). London: Macmillan.
LAING Jacqueline A. (1990). Assisting suicide. Journal of Criminal Law, 54, 106–116.
LAING Jacqueline A. and Wilcox Russell (Eds.) (2013) The Natural Law Reader. Oxford: Wiley Blackwell. see especially chapters on euthanasia.
LAING Jacqueline A. and Oderberg David S (Eds.) (1996) Human Lives: Critical Essays on Consequentialist Bioethics (pp. 196–225). London: Macmillan.