Dr. Vernon Coleman: How My Dad Died (A Horror Story)
"... This is the extraordinary, astonishing, almost unbelievable story of his death and of what followed."
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My father was an inventor, company director and World War II naval veteran. He died on February 28th 2008. He was 87-years-old. The inquest into his death was held in Exeter. Although the inquest was held at my request I did not attend. This is the extraordinary, astonishing, almost unbelievable story of his death and of what followed.
At around 4.00 a.m. on the morning of 5th February 2008 my father got up out of bed and made himself a drink. The pain in his back was terrible and he was having trouble breathing. It wasn’t a new pain. He’d had it before. This time the pain seemed to be mainly referred to his lower ribs at the front of his chest. Knowing that if he rang too soon he would get the emergency medical service and probably be told to take two aspirin and ring his doctor in the morning, he waited until around 9.00 a.m. to telephone his doctor. (The fact that he waited five hours before calling a doctor suggested to me that the pain couldn’t have been too bad and that, maybe, a home visit might have been more appropriate.) He told me that he had a bad night because he had got himself into an uncomfortable position. He needed to see the doctor but didn’t feel up to driving to the surgery. He had a long-standing problem with his back: as the GP should have known, he had chronic osteoporotic spine pain which caused pains all around his chest.
My father telephoned Dr Benjamin Hallmark at Budleigh Salterton Medical Centre. My father was, according to Dr Hallmark, complaining of excruciating pain. But instead of visiting, Dr Hallmark simply told my father (who was in excruciating pain, remember) to dial 999 and arrange for himself to be taken to hospital in an ambulance. The doctor didn’t even bother to make the telephone call.
I believe that if Dr Hallmark had visited, my father might still be alive today – largely because he almost certainly would have decided that my dad did not require hospitalisation. I’m old-fashioned and still believe that a GP has a duty to visit patients who call for help. (Even if an ambulance is also considered necessary.) And my father might still be alive today because it was the sequence of events which followed which led, I believe, to his death. It was, in retrospect, the first of many unfortunate decisions. And it was the beginning of a sequence of disastrous events which would lead to his death just over three weeks later.
My father was taken to Royal Devon and Exeter Hospital where he was given extensive tests. The doctors looking after him confirmed that there was no heart problem. No serious or new problems were found. This wasn’t very surprising. At no point had my father ever had any symptoms of a heart attack. My father still had some pain and asked if he could have more morphine. The ambulance crew had given him some and he had, he said, rather liked the feeling. The doctors with him (a consultant and a junior hospital doctor) instantly said that he didn’t need morphine. They told him that paracetamol or codeine would control his pain. The consultant said that he could go home the following day. My father seemed quite well. He was very alert. At one point I remember him asking the consultant to fetch him a telephone directory. The admitting consultant considered sending my father home again. He decided, however, to keep him in overnight. I know all this because as soon as I heard what had happened I drove to Exeter and I was standing by my father’s bedside at the time. My father was quite well, sitting up in bed taking a very active interest in what was happening. He was most concerned that I should get in touch with a friend with whom he had a luncheon appointment.
The following day my dad asked the doctors if they could do anything about his breathing problems. More investigations were ordered. He was expected to be in hospital no more than another day or possibly two. And then the ward was infected with a diarrhoea and vomiting bug and was closed. My father was effectively imprisoned in the hospital. Because the ward was closed there were no physiotherapists, no occupational therapists and no visitors. I tried to get him moved to a nearby private hospital. But they wouldn’t take him because he was on an infected ward. The nursing home wouldn’t take him for the same reason.
In the next ten days or so he was (I believe) twice infected with a diarrhoea and vomiting bug. He also contracted a chest infection and a urinary tract infection. (The latter developed after he was catheterised. He was catheterised because, like most 87-year-old men, he had been getting up at night to pass urine. Unfortunately, he got an infection and they had to take the catheter out. In my view, anyone who gets a urinary infection from a simple catheterisation has been catheterised by a nincompoop.) The staff insisted that the diarrhoea and vomiting bug was airborne (so it wasn’t their poor hygiene which caused the persistent spread). I didn’t believe them then and I don’t believe them now. Such bugs are largely spread through poor hygiene practices. If the staff really believed the bug was airborne why weren’t they wearing masks? And why were the doors to the ward left wide open? A doctor said the bug was spread by projectile vomiting and this can be true. But that doesn’t make it an airborne infection - unless, of course, one patient vomits directly into the mouth of another. It didn’t seem surprising to me that they were having difficulty controlling the infection. One `expert’ told me that such bugs behave differently in hospitals though they couldn’t explain how the bugs know they are in a hospital. The real problem is: if you don’t know how an infection is transmitted how do you stop it? (The staff suffer from these bugs less than the patients because they don’t eat on the ward and don’t use the same lavatories.)
I wasn’t impressed by the quality of care provided. I was told by one member of staff that my dad had diarrhoea because of the codeine he was taking. (Codeine is more likely to cause constipation). I heard a doctor ask another patient how his bowels were. When told that they were runny the doctor said she would prescribe a laxative.
Although the ward was closed I visited my dad on 15th February. I was allowed to visit because he had suddenly become very ill. When I visited him I found that he was very pink, confused and twitching. When he did wake up he had difficulty in seeing. He was on oxygen and it seemed pretty clear to me that he was getting too much of the stuff and was suffering from oxygen poisoning. These are all classic symptoms of this problem. I asked for the oxygen to be stopped. The oxygen was stopped and the following morning my father was fine.
I spent much of the following week struggling to get my dad out of the hospital. I spoke to him and the staff several times a day, every day. His pain was controlled and he was bored and fed up. I spoke countless times to doctors and nurses on the ward. Eventually, after a flurry of calls on Friday 22nd February, I managed to arrange for my dad (who no longer had the virus and was now safely in a side room) to be moved to the Cranford Nursing Home near to his home to convalesce. He was told that the additional tests they had not been able to do (because of the ward closure) would be conducted as an outpatient. By this time my father wasn’t fit enough to go to his own home. He needed physiotherapy to help him walk again. After two weeks in hospital he had become very weak, though he was still mobile. His spare pyjamas went with him to the nursing home, in a bag. When the bag was opened the pyjamas were thickly stained with the diarrhoea he had suffered on the ward. Not the best way to stop infections spreading.
The hospital had prescribed a regime to control my father’s pain and given him an outpatient appointment for further investigations of his long-term respiratory problem. I was told that after admission to the nursing home he was laughing and joking with the nurses.
I had influenza and was too ill to visit him that weekend (I didn’t want to give him the infection I’d acquired) but I spoke to him several times and he seemed well enough. I thought he was safe now that he was out of the hospital. He received visitors and had his television set moved across from his house. He walked about in the nursing home (he walked so much he made himself tired - he told me that he thought he had overdone things) and I asked him if he thought he would still be able to come away with us for a few days in Sidmouth to celebrate his birthday (3rd March). He said he would and that he was looking forward to it.
My dad wasn’t ready to die. He was looking forward to all sorts of things. We’d just brought him a new printer and fax machine for his birthday and a new gadget-packed mobile phone. Before going into hospital he still drove himself and went out to lunch several times a week.
When he was discharged from the hospital my father’s pain was controlled with a Fentanyl patch. He was, I believe, on a relatively low dose of this. Much stronger patches could have been tried. But on 25th February the nursing home staff called his doctor, Dr Hallmark, because he was again complaining of pain.
The doctor who called on Dr Hallmark’s behalf, was a GP registrar, Dr Stuart Livingston. He overruled the regime which had been carefully prepared by the hospital doctors who had looked after my dad for two weeks and prescribed Oramorph (morphine). The manufacturers of Oramorph state clearly that the drug should not be given to patients with severe respiratory problems. It’s a serious hazard. The drug is a version of morphine and it depresses respiration. Michael Jackson is said to have died of an opiate induced respiratory arrest. And my dad was 87-years-old. In old age drug effects can be dramatically enhanced. Two days later – after several doses of Oramorph – my father was dead. Dr Livingston stated in his report to the coroner, Dr Elizabeth Earland, in support of his action, that he believed the contraindication to be a relative rather than an absolute one. The manufacturer of the drug, however, makes it clear that the contradiction is absolute. To be precise, the company making Oramorph told me: `...the use of Oramorph is contraindicated in any patients with respiratory depression or obstructive airways disease regardless of age.’ My father had chronic obstructive pulmonary disease – a serious respiratory problem. Dr Livingston also suggested that prescribing Oramorph is acceptable in `end stage’ respiratory disease. But my father was not `end stage’ anything. I don’t believe that Dr Livingston had ever met my father before he prescribed Oramorph for him. My father didn’t even think of himself as old. A few weeks earlier he had gone to a club for pensioners and had complained bitterly about it. `It’s full of old people,’ he muttered sourly. He had been driving his car the day before he was admitted to hospital.
When I telephoned him at 9.00 a.m. on Wednesday morning (27th February) my dad was very sleepy and kept falling asleep during our conversation. I put the telephone down and rang a little later. He was still very drowsy, seemed drugged, and had difficulty in breathing. I had spoken to him virtually every day for four years and I had never heard him have as much trouble with his breathing as he had after that day. I guessed that his medication had been changed and asked him what new drug he was on. He told me that he had seen a GP on Monday who had given him morphine. I spoke immediately to a senior member of staff and asked him not to give my father any more of the morphine. I was told that the morphine had been prescribed four times a day and as required. I was horrified and pointed out that since morphine is a respiratory depressant and my father was suffering from severe respiratory problems the morphine would kill him. The staff member agreed that no more morphine would be given. I said I would take responsibility for stopping the morphine and he accepted this. I said I would visit the following day (Thursday).
I telephoned my Father on the Wednesday afternoon at 2.51 p.m. hoping that he would have woken up a little. He had. He was much better. I told him the dangers of morphine and asked him not to take any more. I told him that the drug would kill him if he continued with it. Apart from ‘Goodbye, I love you dad,’ my last words to him were: `If you take any more of that drug it will kill you.’ They haunt me. But he wasn’t very keen on hearing what I had so say. My dad could be incredibly patient. But when it came to medical matters he always wanted immediate solutions. When he started having a little prostate trouble I recommended that he try eating a handful of pumpkin seeds once a day. Twenty four hours after I made this suggestion he telephoned and rather grumpily told me that my suggestion hadn’t worked. Sadly my dad believed that there was a pill for every problem. He liked pills. And GPs like prescribing them. When we cleared out my dad’s house we filled one and a half black dustbin liners with bottles and packets of pills. I went once with him to see a specialist, shortly before his death, because he was finding it difficult to walk as far as he used to be able. `I can’t walk uphill as fast as I could,’ he said. `What are you going to do about it?’ he demanded, staring rather belligerently at the consultant.
My dad agreed that the Oramorph made his breathing worse but said he liked it. He said he wanted to see documentary evidence showing that the drug was dangerous for patients in his condition. I said I would bring him the evidence the following day. My wife did a Web search that evening and printed out some suitable evidence to add to the textbooks I’d picked out.
I was telephoned at around 8.30 p.m. that evening (Wednesday 27th February) by the night nurse. She said my father was a bad colour and was having difficulty breathing. She admitted that he had been given another dose of morphine at 8.00 p.m. and told me that he had subsequently developed serious breathing problems. She told me that his condition had deteriorated alarmingly after he had been given the drug. I said I was planning to visit the following morning and repeated my request that he be given no more of the drug. I told her that in my view morphine would kill him. I said I would be in to see him the following day but hours later he was dead.
On my way down to Exmouth I received a telephone call from the nursing home to say that my dad had died.
Why wouldn’t he listen to me and stop taking the drug? Simple. Some months earlier I had questioned another prescription which had been written for him. (After taking it he developed an irregular heart beat.) When my father had passed on my concerns to his doctor, the doctor had dismissed my worry; reportedly telling my father that, because I wasn’t in practice, I was out of touch and out of date.
When I had seen my dad I asked to see the nursing home’s drug records. The nurse I spoke to immediately said: `It’s about the Oramorph isn’t it?’
After a post-mortem a pathologist concluded that my father had died of his respiratory problem. There was a small amount of Oramorph left in his blood. Could the morphine have helped kill my father by exacerbating his respiratory problems? Would he have been alive today if he hadn’t had that last dose? We will, of course never know any of the answers.
But the doctors at the hospital (where he had been for over two weeks) did not think he needed morphine (or, maybe, thought that it would not be safe for him to take it). The hospital did not regard him as terminal. (He was sent an outpatient appointment for March 13th). He did not complain that his pain had got worse after he had left the hospital. And he went from weak but relatively healthy to dead in less than 24 hours - after being given a drug which the manufacture states he should not have been given.
If he had needed a stronger painkiller why didn’t the GP try a higher dose of the Fentanyl patch instead of prescribing morphine for an 87-year-old man with severe respiratory problems?
An article in Pharmacology advises that the most dangerous side effect of morphine is `respiratory depression’. MIMS magazine for doctors warns that the two first disorders listed as contradictions for Oramorph are respiratory depression and obstructive airways disease. All GPs receive, and should read, MIMS. And according to a leading medical website: `Respiratory depression (with morphine preparations) occurs more frequently in the elderly and debilitated patients, as well as in those suffering from conditions accompanied by hypoxia or hypercapnia when even moderate therapeutic doses may dangerously decrease pulmonary ventilation’. The West Midland Ambulance Service has warned that Oramorph should not be given to patients with respiratory depression or inadequate tidal volume. Oramorph, like all drugs, is particularly likely to be potent when given to elderly patients. Older patients tend to respond more dramatically to drugs than younger ones.
In the end, I decided there was no point in attending Dr Earland’s inquest because the coroner informed me that she had already decided (before the inquest) that Oramorph did not cause my father’s death. She agreed to accept witnesses but suggested that they wouldn’t make any difference to her decision. And she decided not to have witnesses whom I considered vital at the inquest. It seemed to me that if you don’t ask the right people the right questions you aren’t ever likely to come up with the right answers. I felt it had become the sort of inquest where Kafka would have felt at home.
It was suggested by the coroner that if I wanted justice I should take action in the civil courts. I didn’t want damages. What good are damages? The idea of suing in the civil courts reduced my father’s death to the level of a faulty ladder on an uneven pavement. I was, I confess, reminded of Conan Doyle’s remark that `some of these country coroners do think they are tin pot gods’. Conan Doyle was, of course, himself a doctor. He knew of which he spoke. A coroner is a medium level state functionary but one who has a great deal of power over his or her tiny domain, like a local VAT inspector, or a traffic warden. I found the whole inquest experience cold, unhelpful and traumatic. I’ve had friendlier encounters with HMRC. The whole thing was managed with all the subtlety and compassion of an MOT test. I didn’t understand why the inquest wasn’t being held in front of a jury. According to the leaflet I was given at the start of the proceedings, inquests are held with a jury: `if further deaths may occur in similar circumstances’. This was clearly the case in my father’s death. My father’s GP has not admitted that the drug was prescribed inappropriately and has, presumably, not changed his prescribing practices. Other doctors may well be prescribing the drug under similarly inappropriate circumstances. Ergo, there should have been a jury. There wasn’t.
On 3.00 p.m. on 20th August 2008 I met a policeman, the coroner’s representative, at a police station in Devon. He told me that the impression was that I was a bit of a nutter, that the coroner was aiming for `natural causes’ and that the death was not taken very seriously because my dad was 87-years-old when he died. He said none of the other witnesses had been interviewed and weren’t likely to be. We talked for some time. I explained exactly what had happened and he agreed with me that it would perhaps be surprising if the coroner didn’t agree with me that the Oramorph was probably the cause of my father’s death and that negligence was involved. `If he’d been a young child things might have been different,’ said the policeman. `The feeling is that your dad was old and had a long life so what are you going on about?’
I felt his theory explained the curious nature of the coroner who didn’t bark. You don’t get many rights these days if you’re old.
Eventually, after it finally became clear that the coroner had already decided that the Oramorph had nothing to do with my father’s death. I sent her this letter:
`When I started this long and tiring journey I hoped for two things: justice for my father (in the hope, perhaps, of a simple acknowledgement that an error had been made) and an opportunity to prevent the same thing happening again. The second of these was actually the most important. Nothing can change the fact of my father’s death. But it is now abundantly clear that neither objective will be reached. More people will die in exactly the same way as my father died and the judicial system is not going to prevent this happening. What a missed opportunity! There was, here, a clear opportunity to warn doctors of the danger of prescribing inappropriate drugs (particularly to the elderly) with a specific example illustrating the consequences.
Your list of witnesses is disappointing, to say the least. I can think of two specific individuals from the nursing home who should be there. A senior member of staff agreed with me that Oramorph was making my father ill and agreed with me that the drug would kill him and that he should have no more of it. In addition, the nurse who gave the final dose would be able to describe my father’s reaction to the drug and to tell us the time of his death. We know the time he was certified dead but I certainly don’t know the time of his death.
On 7th August you wrote and told me that you intended to call the nurse who `allegedly agreed with you that Oramorph was seriously affecting your father’s condition’ and `the nurse who was on duty when your father died’. But your list now merely includes `a representative from the Cranford Nursing Home’. That could be an administrator. Both the relevant nurses are easily identified and, presumably, traced.
In addition you have no expert representative from the drug company which warns doctors not to give Oramorph to patients with my father’s condition.
My lack of faith in your inquest is increased by the knowledge that you have, quite inexplicably in my view, already decided (before the inquest) that the drug which I am quite certain killed my father played no part in his death. (`Oramorph does not feature as the cause of your father’s death’ - your letter dated 7th August 2009.) The drug company insists that Oramorph should never be given to patients with my father’s condition. (In my experience drug companies do not usually limit their market without good reason.) The theoretical medical evidence suggests that a normal dose of the drug could kill him. Hospital doctors refused to give him a similar drug just days beforehand. The clinical evidence shows that the first dose of the drug affected him adversely. And yet somehow you `know’ that the final dose of the drug, inappropriately prescribed, did not kill him. I have studied the pathologist’s report but I still have no idea how you reached this conclusion.
I would now like to withdraw from the process completely so that I can, at last, begin to mourn and to remember my father rather than fighting over the manner of his death. It has been enormously stressful to see a close relative killed by an inappropriately prescribed drug and to be denied anything remotely resembling proper justice.’
I did not know then how the coroner came to her conclusion. I still do not know.
I made a formal complaint to the General Medical Council (GMC) about Dr Hallmark and Dr Livingston. To my astonishment the GMC agreed with my father’s GPs that any contradiction for the use of Oramorph in COPD patients is relative rather than absolute. They apparently ignored the fact that the drug company which makes Oramorph has an absolute ban on the use of the drug with COPD patients. The drug company stated that Oramorph is contraindicated in any patients with obstructive airways disease. I asked the GMC to explain why the defending GPs’ views were considered more relevant than the manufacturer’s advice. They refused to answer. And they refused to consider evidence from the professional witnesses who observed the effect the Oramorph had on my father.
If I was astonished by that judgement I was utterly dumbstruck by the GMC’s decision that it is acceptable practice for GPs to advise patients living alone, and in excruciating chest pain, to be told to call their own ambulance and then just wait for the ambulance to arrive.
That’s medical care in Britain in the 21st century.
And I think it stinks.
I wrote to the GMC saying that I wanted to complain about their decision. I said I wanted to make a formal complaint about the GMC and the two employees who decided that a clear contraindication to the prescribing of a drug is of no consequence. `Under the Freedom of Information Act, would you please let me have the names and qualifications of the two GMC employees who decided that it is perfectly acceptable for a doctor to ignore a drug company warning not to give a drug.’
I didn’t hear from them again.
The hospital weakened my father. They were, if you like, the picadors. I believe the GP then did the matador’s work by prescribing an unsuitable drug.
In the end, nothing happened. No one was disciplined. No one apologised. Nothing changed.
The hospital believe they did nothing wrong.
Two GPs claimed they did nothing wrong.
The coroner said no one did anything wrong.
The General Medical Council agreed that no one did anything wrong.
I wrote to the police but they didn’t bother to respond to my letter.
But everything you have read is the truth. So, now you decide.
Remember: my dad was given a drug the manufacturer said he should not have been given. Within minutes his condition had deteriorated. He then recovered but was given another dose of the same drug. Within hours he was dead. Neither the coroner nor the GMC thought there was a link between the two events and neither made any attempt to investigate any relationship between the two.
If it had all happened to a child, an asylum seeker or the wife of a minister would the result have been the same? Does being white, male and over 80 diminish the significance of a death? The case seemed very simple to me. A doctor prescribed a banned drug. Abundant evidence shows that the drug made the patient ill. The patient died soon afterwards.
Why should you care? Because you could be next.
I have spent my entire medical career exposing the dishonesties and incompetences of doctors. There is, therefore, no little irony in the fact that I believe that incompetent doctors killed both my parents.
But the fact is I know that my parents were killed only because I know what to look for. I’ve described how and why they died, and how the system did its best to cover up what had happened, not to point a finger but to draw attention to the extent of institutionalised incompetence within the world of medicine.
This wasn’t a case of a patient being given the wrong dose of a drug. It was a case of a patient being given an entirely inappropriate drug. No one has ever apologised, expressed remorse or regret or admitted they made a mistake. So, one has to assume, the same thing will happen again. And again. And again. Prescribed drugs are one of the top killers in Britain today. The wrong drug can kill a patient just as surely as a bullet. How many other deaths are officially dismissed as natural causes? Is this through incompetence or a lack of caring or is it deliberate policy? How many deaths which should be investigated are never reported to the coroner? How many coroners refuse to investigate such cases?
Just how big is the iceberg?
NOTE
The essay above is taken from Vernon Coleman’s book entitled `Why and how doctors kill more people than cancer’. The book is available via the bookshop on www.vernoncoleman.com
Copyright Vernon Coleman October 2025
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Heartbreaking story Dr. Coleman. I believe this happens routinely. Are you familiar with the Grace Schara case, Appleton, WI? It’s a very sad case, needless loss of a wonderful young woman. In her case, the questions are the same as you posed. Incompetence? Deliberate? Evidence at her trial was thorough, well-documented and well-presented, but a jury deliberated a VERY short time and found no fault of any medical providers or institutions. Unbelievable. Makes no sense at all.
My sympathy to you for the loss of your Father at a time before he should have passed. Has to be incredibly frustrating to you when medicine has been your lifelong passion and profession. Thank you for sharing.
I am so sorry about what happened to your dad. My mother also died after being given morphine here in the U.S.
She was living in a private assisted living residence owned by a Hospice nurse.
My mom had cancer, but had not complained of pain. She died during the night after being given morphine. Mom had Mesothelioma and was short of breath. I know that morphine depresses breathing.
What really bothered me is that it seemed wrong that she was given morphine by the owner of the private home and then died. I didn't think that it was proper. I don't believe that the nurse should have been the one to dose her.
When I heard that mom was given morphine, I questioned why, she hadn't complained of pain? I lived in an adjacent state and was going to leave in the morning to go see about mom, but she died that night. I didn't even get to say goodbye.