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Saturday, December 14, 2019

The Supreme Memory Book Is A Complete System For Memorizing Scripture in other memorization books that are out there — you'll be learning Dr. Evans'. Editorial Reviews. About the Author. Dr. Evans memorized the entire King James version of the Want to know our Editors' picks for the best books of the month? . I've been seeking to improve and optimize my memory for the past 2 years. Book Source: Digital Library of India Item sppn.info: William sppn.infoioned.

The Supreme Memory Book By Dr. Evans

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Jackson, Mississippi, for giving me a copy of Evans's classic book about. Scripture memory, How to Memorize, published by The Bible Institute . It is said of Dr. Johnson that he never forgot anything that he had seen, heard or read. Says Sir. Dr. Evans was a Bible teacher with Ph.D., and D.D. (Doctor of Divinity), and In my brand new e-book entitled “Supreme Memory Book”, I've. The Supreme Memory Book Free Download Pdf DOWNLOAD (Mirror #1). Dr. Evans memorized the entire King James version of the.

Nowhere have such arguments been more keenly debated than in the trading port of Bremen, where, in a small park behind the main railway station, there is a ten-metre-high brick elephant; commuters and tourists walk past it every day. Put up towards the end of the Weimar Republic, the stylised monument was conceived as a memorial to and a reminder of the history of German colonialism. Terracotta tiles were set into the plinth, each bearing the name of one of the former colonies.

Speeches delivered to vast crowds gathered in the park for the statues inauguration on 6 July celebrated the achievements of colonialism and demanded the restoration of the lost colonies. Improbably, the elephant survived the SecondWorld War unscathed, although the various inscriptions around the plinth were quickly removed after By the fiftieth anniversary of its construction in , it had become an embarrassment, especially in view of the continuing rule of the South African apartheid regime over Namibia.

Two years later, the elephant was officially declared an anti-colonial monument in defiance of its original purpose, obvious though that was. When Namibia gained its independence, Bremens mayor staged an official celebration around the elephant, and in Sam Nujoma, the Namibian president, unveiled a new plaque inscribed In Memory of the Victims of German Colonial Rule in Namibia on a state visit to Germany.

The elephant is now cared for by an officially recognised society dedicated to tolerance, creativity and multiculturalism. A bronze plaque reminds visitors of the monuments past; nearby a small memorial to the Herero and Nama has been built as a kind of anti-monument. IMAGINING EMPIRE few decades ago, historians searching for the longer-term roots of Nazisms theory and practice looked to the ruptures and discontinuities in German history: the failed revolution of ; the blockage of democratic politics after unification in ; the continued dominance of aristocratic elites over a socially and politically supine middle class; the entrenched power of the traditionally authoritarian and belligerent Prussian military tradition in short, everything, they argued, that had come by the outbreak of the First World War to distinguish Germany from other major European powers and set it on a special path to modernity that ended not in the creation of a democratic political system and open society to go with an industrial economy, but in the rise and triumph of the Third Reich.

Such arguments were discredited by the s, as it became clear that imperial Germanys middle classes had been far from supine, its political culture was active and engaged, and its aristocratic elites had lost most of their power by the outbreak of the First World War.

The revolution was shown to have transformed German political culture, not to have restored the old regime. Comparisons with other countries revealed similar deficits of social mobility and openness in Britain, tendencies to authoritarianism in France, military domination in Austria and more besides. But if there was no domestic special path from unification to the rise of the Third Reich, where should historians look instead?

This view of German history is perhaps possible only at a time when we have become acutely aware of globalisation as a contemporary phenomenon, but it has thrown up many vital new interpretations and generated a growing quantity of significant research that links Germanys relation to the world in the nineteenth century with its attempt under the Nazis to dominate it.

Now this research has been brought together in Nazi Empire , a powerful and persuasive new synthesis by Shelley Baranowski, previously known for more specialised studies, notably an excellent book on the Nazi leisure organisation Strength through Joy. Baranowskis story begins in the mids, when Bismarck reluctantly agreed to the establishment of colonial protectorates in order to win the support of National Liberals and Free Conservatives in the Reichstag. Bismarck was wary of the financial and political commitment involved in full colonisation, but he was soon outflanked by imperialist enthusiasts, merchants and adventurers, and by , when he was forced out of office, Germany had a fully fledged overseas empire.

It was, admittedly, not much to write home about.

The scramble for Africa had left the Reich with little more than leftovers after the British and the French had taken their share: Namibia, Cameroon, Tanganyika, Togo; elsewhere in the world, New Guinea and assorted Pacific islands such as Nauru and the Bismarck Archipelago. A younger generation of nationalists, who did not share Bismarcks sense of the precariousness of the newly created Reich, complained it was an empire on the level of the late nineteenth-century Spanish or Portuguese empires, hardly worthy of a major European power.

Moreover, the colonies Germany did possess proved in more than one instance peculiarly difficult to run. The colonial regime responded with policies of extreme harshness.

Even more notoriously, in Namibia, the Hereros and Nama were driven into the desert without supplies, their waterholes poisoned, their cattle sequestered; they died of disease and malnutrition. Victory was followed by an apartheid regime with laws and regulations forbidding racial mixing and reducing the Africans to the status of poorly paid labourers. Already, however, German policy had begun to move towards the acquisition of new colonies. Where were they to come from?

With Kaiser Wilhelm IIs assumption of a leading role in policy-making, Germany began the construction of a large battle fleet in By focusing on heavy battleships rather than light, mobile cruisers, the navys creator, Admiral von Tirpitz, was adopting the high-risk strategy of working towards, or at least threatening, a Trafalgar-style confrontation in the North Sea that would defeat or cripple the British, whose domination of the seas was regarded as the major obstacle to German imperial glory, and force them to agree to an expansion of the German overseas empire.

Germany now adopted an aggressive world policy, aiming to boost the status of its empire and gain a place in the sun comparable to that of other European powers. Soon, uncontrollable imperialist enthusiasms were bubbling up from the steamy undergrowth of pressure-group politics. These focused on Europe as much as overseas. A large chunk of Poland, annexed in the eighteenth century, belonged to Germany, and the government began to encourage ethnic Germans to settle in areas dominated by Polish-speakers, but although , moved there in the imperial period, that was by no means enough to replace the , ethnic Germans who migrated west between and in search of a better life.

The influential Pan-German League went even further, pressing the government to contemplate the annexation of Holland, Flanders, Switzerland, Luxembourg, Romania and the Habsburg Empire, all of which they thought of as German lands, and to couple this with the removal of civil rights from Germanys tiny Jewish minority.

Once German domination of Europe had been achieved, the expansion of the overseas empire would inevitably follow. Under such influences, Social Darwinism gained increasing currency in government circles, propagating a view of international relations as determined by a struggle between races Germanic, Slavic, Latin for survival and ultimately domination.

A large colonial empire was obviously Germanys due. Nevertheless, colonial ideology continued to be opposed by the two largest political parties, the Marxist-oriented Social Democrats and the Catholic Centre, who vehemently condemned German colonial atrocities in In , these parties, together with left-wing liberals, managed to block the introduction of anti-miscegenation measures in Germany on grounds of the sanctity of marriage for the Catholics and the universality of human rights for the socialists and liberals.

Even so, the resulting Citizenship Law, uniquely among European nations, defined citizenship not by residence but by community of descent.

When war threatened in , the pressure from the Pan-Germans made it at the very least easier for the government to get involved, while the Social Darwinist convictions of some of the major actors weakened the will to find a peaceful way out of the crisis. Once war had broken out, the government formulated a secret programme that aimed for major territorial acquisitions and the economic and military subjugation of most of Europe, as well as the seizure of the French and Portuguese possessions in sub-Saharan Africa.

These aims went far beyond those of the British and French; hardliners in the leadership, driven by the military stalemate in the west, Allied control of the seas and growing food shortages at home, demanded even more far-reaching annexations.

After the Bolshevik Revolution in and the effective capitulation of the Russians at Brest-Litovsk in March , more than a million square miles and fifty million people, together with most of Russias coal, iron and oil deposits and half its industry, were lost to Germany and its Turkish ally.

A million German troops helped impose a ruthless military dictatorship in the occupied areas, which stretched from Estonia in the north through huge swathes of Belarus and Ukraine to the north-eastern hinterland of the Black Sea in the south.

Along with economic exploitation and the brutal suppression of nationalist movements came the imposition of a new racial order in which the inhabitants of the region were explicitly treated as secondclass citizens, foreshadowing the regime that would be imposed by the Nazis a quarter of a century later.

In the peace settlement that followed defeat in , Germany lost all its overseas colonies, 13 per cent of its territory in Europe including Alsace-Lorraine to France, and industrial areas in the east to the newly created state of Poland , and almost all its military equipment.

Its armed forces were restricted to , men, and the government had to agree to the payment over subsequent decades of large sums of money in reparations for the economic damage caused by the war.

These terms caused general disbelief and then outrage; after all, the war had ended while German troops were still on foreign soil, and military defeat had been far from total. Moreover a fact often overlooked by historians British and French troops occupied the Rhineland for most of the s, providing a constant reminder of Germanys subjugation to foreign powers.

In , when the Germans fell behind with reparation payments, the French sent an expeditionary force into the industrial region of the Ruhr to seize key resources, causing further resentment Yet did this amount, as Baranowski claims, to the colonisation of Germany by the Allies?

But by the mids the violent clashes between revolutionary and counter-revolutionary forces that had brought machine guns and tanks on to the streets of Germanys major cities in the immediate aftermath of the war had subsided and the economy had stabilised. The negotiating skills of Gustav Stresemann, the long-serving Foreign Minister, brought readmission into the international community, the renegotiation of reparations and the removal of the occupying troops.

There is little evidence of any widespread feeling among Germans that the country had been colonised; only among extreme antisemites was there a conviction that the Weimar Republic was controlled by an international Jewish conspiracy, but even here the language of colonisation can rarely be found, and it must also be remembered that the Nazi Party did so poorly in the elections of , winning less than 3 per cent of the vote, that it soft-pedalled its violent antisemitism in subsequent elections.

The antiJewish disturbances of the postwar years were both less widespread and less representative of public opinion than Baranowski implies. Only once the Depression of the early s had bankrupted banks and businesses and put more than a third of the workforce out of a job did the Nazis win mass support; and only when they were brought into power as the conservative elites coalition partners the elites were seeking popular legitimacy for their plans to destroy Weimar democracy did they unveil their visceral antisemitism once more and begin to implement it in a series of decrees and laws backed by stormtrooper violence against Nazisms opponents, above all on the left.

By this time, the idea of a German empire had come to be dominated not by overseas colonies, which had been the concern only of small and impotent minority pressure groups during the Weimar years, but by the vision of a European empire, one that built on the experiences of the First World War but went far beyond them.

Still, memory of Germanys overseas empire remained and was even revived by the Nazis. How far did the colonial experience influence the policy of extermination under Hitler? In the first half of the Nazis set up hundreds of concentration camps, into which they drove more than , of their political opponents, using them for forced labour and treating them so brutally that many hundreds died. But these bore little resemblance to the camps in which the Hereros had been starved to death in Namibia, and in any case the idea of concentrating civilian populations in prison camps was by no means a German invention: it dated back at least as far as US campaigns against Native Americans in the s.

The Nazis did see their camps as a kind of counter-insurgency tool, but their primary purpose was to intimidate and re-educate opponents of the regime, who were brutalised until they agreed not to mount any further resistance. Almost all the inmates had been released by , by which time the task of repression had been turned over to the regular police, the courts and the state prison system.

If there was a colonial precedent, then, as Baranowski remarks, it had been totally transformed and owed far more to the political polarisation of Europe after the Bolshevik Revolution at roughly the same time, similar institutions emerged in the Soviet Union, owing nothing at all to colonial precedents. There was no parallel in the Soviet Union, however, to the racial policies adopted by the Nazis. How much did the Nazis imposition of racial hygiene, the laws against intermarriage and sexual relations between Jews and non-Jews, and the forcible sterilisation of up to , hereditarily inferior Germans, owe to Germanys colonial experience?

As Baranowski persuasively argues, there were striking precedents in the anti-miscegenation laws passed in pre Namibia, the segregationist response to colonial insurrection and the more extreme policies advocated by the Pan-Germans during the debates over the Citizenship Law of Imperialism, she remarks, linked the two bourgeois phobias of socialism and racial mixing, in which workers were imagined much like natives.

The concepts were the same; only the practice was radicalised. There were personal continuities, too, in many different areas, including medicine, eugenics and racial anthropology the anthropologist Eugen Fischer used his research on mixed-race groups in German South-West Africa before the First World War to argue against racial mixing during the Third Reich, when medical scientists who had trained in his institute, such as the Auschwitz doctor Josef Mengele, played a major role in implementing eugenic policies.

Yet in the end these continuities were less important than the discontinuities that Baranowski enumerates.

Arguing persuasively against the trend of much recent historical opinion, she insists repeatedly on the centrality of terror and violence to the Nazi seizure and practice of power, which marked a crucial rupture with Weimars administration of welfare and policing.

The crushing of the labour movement, the arrest or exile of Jewish and liberal public health and welfare officials, and, she might have added, the destruction of the free press and news media, removed the major obstacles to the deployment of eugenicist policies by the state, while the rapid growth of the racially obsessed SS under Himmler pushed on the central implementation of policies such as the mass sterilisation of the allegedly mentally ill and handicapped on a scale unrivalled in any other country.

Uniquely, too, this policy, coupled with the exclusion of Jews from economic and social life on racial grounds, was designed to pave the way for a war of imperialist expansion in the east, and during the war itself was transformed into a campaign of mass murder in which , mentally ill and disabled Germans were killed by Nazi doctors. The symbiosis of racial policy and war became even clearer from onwards.

The Germans all but eliminated any distinction between combatants and civilians, abandoning any attempt to follow the laws and conventions of war to which with rare exceptions they adhered in the west.

SS and army troops alike regarded the Poles as savages, the Jews as a lower species of being. All this was repeated on a larger scale following the invasion of the Soviet Union in June , reflecting not only prejudices against Slavs and eastern Jews widespread even in the working class before but also the practices common among European conquerors of colonial territories since the Spanish invasion of the Americas in the sixteenth century.

Yet, as Baranowski points out, the mass expulsion or killing of native populations in the colonial setting of the nineteenth century often followed frontier conflicts on the ground between European settlers and indigenous peoples over land and resources. Administrations in the imperial metropoles often tried to restrain settlers greedy for land and labour, though they generally ended up tolerating and eventually endorsing their rapacity.

Even the genocidal decision in the Namibian war was taken locally, by a military commander who brushed aside the reservations of the colonial governor and his superiors in Berlin, and colonial atrocities frequently aroused fierce criticism at home.

The Nazis, by contrast, launched their war of racial subjugation and extermination in the east without the slightest provocation and in the absence of any doubts or criticisms, except on the part of a handful of conservative army officers. Moreover, throughout the war they coordinated and directed operations from the centre, acting on directions from Hitler himself. This is not to deny that there were disputes within the Nazi elite over the implementation of ethnic cleansing and annihilation.

But the basic direction of policy was clear, culminating in the General Plan for the East, the extermination by starvation and disease of at least thirty million and possibly as many as forty-five million Slavs and the resettlement of most of Eastern Europe by German colonists. Here indeed, as Baranowski puts it, was the Nazi place in the sun. The natives were to be separated out from European settler society, to be sure, but German administrators were to educate, feed and improve the health of indigenous Africans, developing the colonial economies to aid the supply of raw materials and foodstuffs for the metropole.

This was partly because the Nazis did not see African countries as a major source of German settlement, but also because their inhabitants posed no threat of the kind they imagined was constituted by the Slavs and, above all, the Jews. The destruction of the Slavs and Jews was linked in Nazi policy to the purification of the German race itself, as it was not in the colonial situation.

Indeed, SS units even roamed Eastern Europe in search of racially valuable blond, blue-eyed children, kidnapping tens of thousands of them and arranging their adoption by German parents under new identities a policy unthinkable in colonial Africa.

Finally, Nazi policy in Eastern Europe was driven at least in part by the immediate imperatives of ensuring an adequate food supply for Germany itself, whose agriculture was in no way able to feed the Reich and its armies.

Once more, therefore, the Nazis radicalised earlier imperialist practices or departed from them in significant respects, rather than simply continuing them. How can the Nazi extermination of the Jews be fitted into the colonial paradigm?

Certainly, prewar radical nationalists incorporated antisemitism into their vision of international relations as a Darwinian struggle for survival and supremacy between races. The policies of segregation, deportation and expropriation to which Germanys and then Europes Jews were subjected all had their precedents in the colonies. But the deliberate scouring of a whole continent and potentially as suggested by the minutes of the conference held at Wannsee to discuss the implementation of the Final Solution of the Jewish Question in Europe the entire surface of the globe for Jews to be carried off to assembly-line extermination in gas chambers or killing pits had no precedent.

As she points out, other European powers engaged in similar policies, all of which, including those of the Germans, were designed above all to destroy the economic independence of conquered populations and turn them into a docile labour force or, in areas deemed suitable, clear them out to make way for settlement. Something like this was what the Nazis planned in Eastern Europe, and at some points in the process Nazi administrators did use Jewish labour for the war economy as well, but in the long run this was, as they put it, just a slower form of annihilation through labour, Vernichtung durch Arbeit.

While the General Plan for the East undoubtedly envisaged the genocidal elimination of tens of millions of Slavs, it was driven by ideological imperatives fundamentally different from those of the Final Solution, which designated the Jews as the world-enemy, the Weltfeind, not a regional obstacle posed by savages but a world conspiracy mounted by a cunning and ruthless enemy designed to destroy the German nation entirely.

These arguments will be discussed and debated for a long time to come. Although Baranowski set out to write a textbook, she has produced something much more important: a skilful and carefully nuanced synthesis of some of the most productive ideas to have emerged in the debate about the origins of Nazism and Nazi extremism in the past few years.

Reflecting current concerns, these focus not so much on how or why the Nazis came to power, as on what they did once they had achieved it, above all during the war. From this point of view, they are addressing a rather different set of questions from those posed by the old special path thesis. Baranowskis book nonetheless puts them clearly on the map, debates their pros and cons with subtlety and sophistication, and should be read by anyone interested in the calamitous and ultimately exterminatory path taken by German history in the twentieth century.

As he was recovering, he was told of Germanys surrender and the overthrow of the Kaiser. Again, he later wrote, everything went black before my eyes. He went on: And so it had all been in vain. In vain all the sacrifices and privations; in vain the hunger and thirst of months which were often endless; in vain the hours in which, with mortal fear clutching at our hearts, we nevertheless did our duty; and in vain the death of two million.

Was it for this that these boys of 17 sank into the earth of Flanders? Was this the meaning of the sacrifice which the German mother made to the fatherland when with sore heart she let her best-loved boys march off, never to see them again? Like many others in Germany, Hitler struggled to find an explanation for Germanys apparently sudden collapse. How could it all have gone so wrong, so quickly?

Defeat was all the more puzzling since only a few months before, in spring , victory seemed within the Kaisers grasp. Mrs Horton and her family were his private patients.

He was paid a monthly fee for his services. Mrs Horton had consulted him a few times in the past for sinus and chest infections and for pain in her neck. He had given her repeat prescriptions in the past for medication for her sinus problems. The prescription to which this case relates is dated 4 July The medication which Dr Evans prescribed for Mrs Horton was 4 mg. That was eight times the strength of her previous tablets, and Dr Evans prescribed 28 of them.

Until relatively recently, both Dr Evans and Mrs Horton were under the impression that this was the only time that Dr Evans had prescribed dexamethasone for her. There were significant differences between their accounts about the circumstances in which it had been prescribed.

In particular, Dr Evans was saying that Mrs Horton had told him that the dose of dexamethasone she was on was 4 mg. But what was common to both accounts was that Mrs Horton had asked for the prescription as a matter of urgency because she was about to go abroad.

That led Lloyds to investigate Mrs Horton's whereabouts during July , and when the documents she disclosed failed to demonstrate that she had left the country within a day or so of 4 July, Lloyds alleged that Mrs Horton had deliberately misled Dr Evans over the reason why she wanted the prescription urgently, and even adopted Dr Evans' case that she had told him that she was on 4 mg.

However, on 22 June , Lloyds disclosed two pages from the private prescriptions book maintained at its Selsdon branch which showed that the prescription of 4 July was the second prescription of dexamethasone for Mrs Horton which Dr Evans had prescribed. The first had been on 8 June , and it had been for tablets of the correct strength 0. That completely undermined Dr Evans' case that Mrs Horton had told him that she had been on 4 mg.

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As it was, those pages showed that it was this earlier prescription which had had to be dispensed as an emergency, whereas the later prescription had not. As a result, Lloyds unreservedly withdrew the allegations that Mrs Horton had told Dr Evans that she was on 4 mg. The first prescription. I shall return later to why Mrs Horton may have been misled into thinking that the prescription of 4 July was the only time Dr Evans had prescribed dexamethasone for her.

Since her claim against Dr Evans has been settled, it is no longer necessary for me to investigate in detail the circumstances in which the earlier prescription which had been dispensed on 8 June came to be issued.

But I find that what is likely to have happened is that elements of what Mrs Horton originally said about how she had got the prescription of 4 July in fact applied to the earlier prescription.

The probability is that for one reason or another perhaps because she was about to run out of her existing supply, perhaps because she was about to do a lot of overseas travel she wanted a repeat prescription of dexamethasone urgently.

But when she telephoned the NHS practice and asked for one, she was told that she would have to attend the surgery herself. She was very busy at work then and did not have the time to visit the surgery during its opening hours.

Instead, she spoke to Dr Evans over the telephone, and asked him for a repeat prescription for a month's supply of dexamethasone, telling him that she was taking it for an adrenal deficiency, but that she did not have the time to go to her NHS surgery for a prescription for it. She must have told him the strength of the tablets she was on, because he prescribed her with 28 x 0.

Dr Evans has claimed that he had been uncomfortable about prescribing her with dexamethasone without seeing her, and that he had told her to come and see him at a later date for a full medical check-up. That may be so, but he proceeded to provide her with the prescription nevertheless. It is likely that he telephoned Lloyds' Selsdon branch and told them to dispense 28 x 0. I say that because the manager of the branch wrote in the private prescriptions book that Dr Evans had requested the pharmacy to provide the dexamethasone as an emergency, and because someone else had written at a later stage that the prescription for it had been received from Dr Evans.

And it is likely that the prescription was collected from Dr Evans' surgery by Natasha Hassell, who was Mrs Horton's children's nanny. Certainly, Mrs Horton does not recall ever collecting any prescription for dexamethasone from Dr Evans and taking it to the pharmacy herself or leaving the pharmacy with the dexamethasone herself after the prescription for it had been dispensed. Although that prescription has not survived, there is now no doubt about what it was for or that it was dispensed at Lloyds' Selsdon branch on 8 June in view of a the entry for that day in the private prescriptions book maintained at the branch and b a computerised entry for that day in Lloyds' patient medication records.

I should say something about Lloyds' patient medication records. Whenever a prescription is dispensed, relevant details of the prescription are entered into a computerised system. The system serves three functions relevant for present purposes. First, it displays for the use of the pharmacist any previous medication dispensed for the patient.

Secondly, it produces a label to be attached to the medication which is currently being dispensed. Thirdly, a continuous record of the patient's medication can subsequently be retrieved.

The patient medication record for Mrs Horton which was subsequently retrieved shows that at 4. The second prescription. Against that background, I turn to the prescription to which this case relates, the prescription of 4 July That has survived unlike the earlier one.

It is in Dr Evans' handwriting, and it differed from the previous one in two critical respects. First, although the prescription was for 28 tablets of dexamethasone, it was silent about the dose, i.

Secondly, the strength of the tablets of dexamethasone being prescribed was 4 mg. The circumstances in which that prescription came to be provided are less clear than they might have been since Mrs Horton thought until recently that this was the only prescription she had got from Dr Evans for dexamethasone, and the earlier witness statement she made in these proceedings about this prescription may in fact have been describing the circumstances in which she had got the earlier prescription.

But it is likely that what happened was that she telephoned Dr Evans on 4 July and asked him to give her another prescription for a month's supply of dexamethasone. Although he may have been uncomfortable about prescribing her with dexamethasone for a second time without seeing her, he nevertheless proceeded to prescribe it for her, though in doing so he prescribed her with tablets eight times the strength as those he had prescribed for her a month earlier.

The dispensing of the second prescription. This prescription was also dispensed at Lloyds' Selsdon branch. The pharmacist who dispensed it was N'Guessan Gabla, who was the manager of the branch at the time. We know that it was he who dispensed it because a the cost of dispensing the prescription was noted on the prescription in his handwriting, and b it was he who wrote the relevant entry in the private prescriptions book. Indeed, we know from the earlier entry in the private prescriptions book that Mr Gabla had dispensed the previous prescription of 8 June as well.

But this time the prescription was not dispensed on the same day that Dr Evans had prescribed it. Instead, it was dispensed at 4. That appears from entries in Mrs Horton's patient medication record and in the private prescriptions book. Since Ms Hassell was due to take the children to see Dr Evans because they had nasal infections at the time, it is likely that this prescription as well was collected from Dr Evans' surgery by Ms Hassell, to whom at Ms Hassell's suggestion Mrs Horton had given the bottle containing the tablets previously prescribed by Dr Evans to remind him of what he was to prescribe.

Ms Hassell then took the new prescription to the branch to be dispensed. The upshot was that Mrs Horton never actually saw it. But it is not possible to say whether the prescription was collected from Dr Evans' surgery and taken to the pharmacy on 4 July, only to be dispensed on the following day, or whether it was collected from the surgery and taken to the pharmacy on 5 July where it was dispensed the same day, or whether it was collected on 4 July and only taken to the pharmacy on 5 July.

Ms Hassell was not asked to give evidence on the topic, even though she had made a witness statement albeit unsigned which is in the possession of Mrs Horton's solicitors. I shall return later to the relevance of when the prescription was actually taken to the pharmacy. Although the prescription was for 28 tablets of dexamethasone with a strength of 4 mg. It was only available in 0. So Mr Gabla decided to dispense double the quantity of the tablets prescribed, though at a strength of 2 mg.

That made 56 tablets, but he dispensed 55 because the branch had only 55 in stock. When Mr Gabla entered the prescription into the computerised system, he saw that the branch had prescribed medication for Mrs Horton in the past. Dexamethasone had been prescribed for her on seven previous occasions, including the only other occasion that of 8 June when it had been prescribed by Dr Evans. The details which came up on the screen were as follows: Mr Gabla says that he noticed that the strength of the tablets being prescribed on this occasion was eight times the strength of the dexamethasone prescribed in the past.

He therefore looked up dexamethasone in the British National Formulary "the BNF" , which sets out details of medication which pharmacists can dispense. That referred to the "usual range" for dexamethasone as being "0. Since the prescription was for tablets of a strength which came within the usual range, Mr Gabla did not think that he needed to question the accuracy of the prescription.

It is true that Mr Gabla did not say in his witness statement that he actually looked dexamethasone up in the BNF. But on a fair reading of his witness statement he is claiming to have been aware of the therapeutic range for dexamethasone at the time, and I think that he is likely to have known that as a result of looking dexamethasone up in the BNF.

I find that it was with that knowledge that he proceeded to dispense the prescription in accordance with its terms, except that he substituted double or at any rate almost double the number of tablets for the quantity which had been prescribed to reflect the fact that he was dispensing tablets at half the strength of what had been prescribed. As it is, Mr Gabla's awareness or otherwise at the time of the therapeutic range of dexamethasone in fact made no difference to what he did since he would still have dispensed the prescription according to its terms in any event either because he knew that the strength of the dexamethasone being prescribed was within its usual therapeutic range or because he thought that he had to dispense the prescription without question.

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Mr Gabla also says that he noticed that the prescription was silent about the dose. Again, I have no reason to doubt that. He had to identify the dose when entering the details of the prescription in the computerised patient medication record system, and that would inevitably have resulted in him noticing that the prescription did not mention how frequently or in what quantity the tablets had to be taken. He therefore decided that the label should merely record that the dose was to be in accordance with such instructions as Dr Evans had given.

So the entry in Mrs Horton's patient medication record for that day did not merely show that 55 tablets of dexamethasone of a strength of 2 mg.

That meant "to be taken as directed by your doctor". The bottle containing the tablets which Mr Gabla dispensed has not survived, and the disc containing Mrs Horton's patient medication record has been mislaid since a copy of it was made at the request of Mrs Horton's solicitors in It was argued that Mr Gabla must have realised that, although the prescription was silent about the dose, Dr Evans had had one tablet a day in mind.

That was how Lloyds' Superintendent Pharmacist and an expert endocrinologist had both read the prescription. And the experts on pharmaceutical practice agreed that a pharmacist "may reasonably [have] infer[red]" that from the language of the prescription and Mrs Horton's medication history.

But I have to say that I am sceptical about that. It is true that a prescription of 28 tablets implied a number of weeks' supply, since 28 is divisible by the number of days in a week.

Yet that could have meant two tablets a day for 14 days which would at 8 mg. To the suggestion that Mr Gabla would have thought that Dr Evans could not have had in mind half a tablet a day for 56 days, because otherwise he would have prescribed 56 tablets with a strength of 2 mg. In short, these possibilities are no less likely than Dr Evans having intended to prescribe one tablet a day for 28 days.

It follows that I can see how a pharmacist might think that Dr Evans had intended to prescribe one tablet a day, but I also think that a pharmacist would have been wrong to assume that to be the case without question. As it is, having seen Mr Gabla give evidence, I do not think that he ever applied his mind to what Dr Evans had intended about the dose.

For him, once the dose had not been stated, the only question was whether the strength of the tablets was within the usual therapeutic range. I am sure that Mrs Horton did not notice that she had been provided with twice as many tablets as Dr Evans had previously prescribed for her and twice as many as she had been expecting. That is not particularly surprising: she had no reason to suppose that she had not been prescribed the quantity of tablets she had asked for.

She began to take them immediately, because she had forgotten to retrieve from Ms Hassell the bottle containing the remaining tablets previously prescribed by Dr Evans. She continued taking one of them once a day throughout the month of July. I find that she had not bothered to read the label on the bottle, and therefore did not know that she was now taking four times the dose which was appropriate to her condition. After all, she had been taking one 0. There was no evidence whether 2 mg.

But even if they did, Mrs Horton had taken dexamethasone or decadron produced by different manufacturers in the past, and had known there to be small differences between them in size, shape and packaging.

In the circumstances, I find that any small difference in appearance between 2 mg. I return to the relevance of when the prescription of 4 July was taken to the pharmacy. The suggestion was made that, if there was a day's delay between when it arrived at the pharmacy and when it was dispensed, that may have been because the pharmacist who first saw it on 4 July had questioned its correctness with Dr Evans, and it was only dispensed once its correctness had been confirmed.

I reject that possibility for two reasons. First, if Dr Evans had been told by the pharmacist that Mrs Horton's prescriptions in the past had all been for tablets of dexamethasone with a strength of 0. Secondly, if the correctness of the prescription had been questioned, there would have been a note to that effect in the private prescriptions book.

There was no such note. The prescription provided by Dr Elwell. She had been experiencing problems with her marriage.

Although Mrs Horton was not feeling in any way unwell as a result of the four-fold increase in her medication, Mrs Vernon suggested that Mrs Horton had a complete medical check-up, and that she should see Dr Russell Elwell, a general physician with a surgery in Westfield, who was a good friend of Mrs Vernon as well as being her physician.

Mrs Horton had known him socially for many years, but she had never been his patient. She saw him at his surgery on 30 July In the course of this consultation, Mrs Horton asked Dr Elwell for a repeat prescription for the dexamethasone she was taking. He gave her a prescription for 90 tablets of dexamethasone with a strength of 4 mg. Dexamethasone was at that time available in the United States in 4 mg.

These were the tablets which Mrs Horton began to take a couple of days later after she returned to the United Kingdom and had mistakenly left the bottle containing what was left of the tablets dispensed on 5 July in a hotel room. She did not know the strength of the tablets prescribed by Dr Elwell.

She thought that they were 0. She only took one a day, but they were eight times the dose which was appropriate to her condition, and her health was eventually to break down as a result of it.

How did Dr Elwell come to prescribe dexamethasone tablets with a strength of 4 mg. Both he and Mrs Horton say the same thing. During the consultation, she told Dr Elwell about her adrenal deficiency, and that she had been prescribed dexamethasone for it for many years. When she asked him for a repeat prescription, she showed him the bottle she had got on 5 July , and he took the strength of the dexamethasone she was on from its label.

Mrs Horton did not know what was on the label at the time: she assumed at that stage that it showed 0. She assumed then that it must have referred to a dose of two tablets a day for Dr Elwell to have prescribed 4 mg.

Dr Elwell says much the same thing, though he relies in addition on the medication worksheet on which the medication he was prescribing was, I find, recorded contemporaneously.

Although the part of the entry written by his nurse shows that he was prescribing 90 x 4 mg. He therefore assumes that the label must have referred to a dose of two tablets a day for him to have recorded what he did in his medication worksheet and to have prescribed 4 mg.

I should mention one possibility which was advanced by Mr Jeremy Stuart-Smith QC for Mrs Horton, which was that Mr Gabla must have written something on the label over and above what the computerised system printed to show that Mrs Horton was supposed to be taking 4 mg. The principal plank of that argument was that Mr Gabla would have assumed that although the prescription was silent about the dose, Dr Evans had had a dose of one tablet a day in mind.

But that plank falls down in view of my findings in [21] above that a any pharmacist who thought that would be jumping to a conclusion which might well not be the right one, and b in any event Mr Gabla himself never wondered what Dr Evans had intended should be the dose. I do not for one moment think that even if Mr Gabla had thought that Dr Evans had had in mind a dose of one tablet a day, he would have written anything on the label to supplement or override what was printed on it.

That would have resulted in a mismatch between what the patient medication record said the label showed and what the label in fact showed. That is not something which Mr Gabla would have been prepared to sanction.

If he had wanted to add something to the label, he would have retyped the label altogether, which was something which the branch procedures manual contemplated. We know that he did not do that: if he had, the patient medication record would have shown that a different label had been printed. I return to the assumption that both Mrs Horton and Dr Evans made that the label must have referred to a dose of two tablets a day for Dr Elwell to have prescribed 4 mg.

I have no doubt that this assumption was wrong. In the light of the patient medication record, the label could not have stated what the dose was. It stated only the strength of the tablets 2 mg.

But since I accept the evidence of Mrs Horton and Dr Elwell that she showed him the bottle she had been given on 5 July , it must have been something else which made Dr Elwell think that the prescription which had resulted in the label on the bottle had been for 4 mg. There is only one possibility, and that is that Dr Elwell thought that the bottle represented four weeks' supply of dexamethasone. After all, 55 x 2 mg. The critical question is why Dr Elwell thought that the bottle represented four weeks' supply.

One possibility is that Dr Elwell had no reason for thinking that, and simply assumed that it did. But much the likelier possibility and accepted by Mr Moxon-Browne to be the likelier one is that Mrs Horton had said something to him which made him think that the bottle represented four weeks' supply. Although she does not think that she told Dr Elwell that, and although Dr Elwell is convinced in my view, wrongly that he got the dose from the bottle, I think that the likeliest scenario is that Mrs Horton told him that the bottle represented four weeks' supply.

That would not have been surprising. The prescription which had resulted in the label had been intended by Dr Evans to represent four weeks' supply, and as I have found, Mrs Horton did not realise that the bottle had contained more tablets than would have been appropriate for a four weeks' supply of dexamethasone at the strength she thought the tablets were.

It would have been entirely natural for her to have told Dr Elwell, at some point in their conversation about a repeat prescription for her, that the bottle represented four weeks' supply.

In that way, Dr Elwell came to think that Mrs Horton was on a daily dose of 4 mg. That is entirely consistent with what he recorded on the medication worksheet. The discovery of the misprescription. By October , Mrs Horton was becoming increasingly conscious that something was not right with her health.

She was becoming aggressive and on edge. On one occasion, she experienced a panic attack. She found herself unable to shake off a sense of anxiety which she had not experienced before. She had also begun to notice some physical changes: she would eventually experience a range of symptoms she began to lose weight, cuts would not heal, small bumps would form bruises, her eyes were protruding, her face appeared rounder and she grew unwanted hair and some of these had become apparent by then.

Her high level of fitness meant that they appeared more gradually than for a person of average fitness. She did not know what the problem was, but had no reason to suppose that it was anything to do with the dexamethasone she was taking. By the end of October, she was running out of the dexamethasone which Dr Elwell had prescribed. So she sent him an e-mail asking for another repeat prescription for 90 tablets which her mother could bring over to the United Kingdom on her next visit.

That would make it unnecessary for her to get repeat prescriptions for lesser amounts in the United Kingdom. She mentioned in the e-mail that the prescription should be for 0. Dr Elwell's immediate response was to tell her that she had been on 4 mg. He told her to reduce her dose by 0. It was within a day or so of this that her health broke down completely. She went to the Accident and Emergency Department of the Mayday University Hospital in Croydon a number of times in the last week of October, but her paranoia and anxiety attacks increased in their intensity, and on 1 November she was admitted to the Priory Hospital.

What happened the following spring explains why Mrs Horton had been misled into thinking that the prescription of 4 July had been the first time that Dr Evans had prescribed dexamethasone for her. Three points should be made.

The first is that by then she had obtained a copy of the prescription. She sent it to Dr Evans on 29 March , asking him for an explanation for why he had prescribed her 4 mg.

He did not reply until 24 May When he did, he referred to the occasion on which he had prescribed her with 4 mg. Secondly, Mrs Horton had, in the meantime, gone to the pharmacy where the prescription had been dispensed as part of her search to find out what had gone wrong. That was on 10 May She was shown her patient medication record, but since that did not identify the doctors who had issued any of the prescriptions, it did not occur to her that Dr Evans might have issued any of the earlier ones.

After all, if he had prescribed 0. Thirdly, she was also shown by the pharmacy the branch's private prescriptions book, but she claims that the only entry in it which was drawn to her attention was the entry for the prescription of 4 July she was not shown the entry for the prescription of 8 June I have no reason to doubt that. The aftermath The condition which the overdose of dexamethasone induced was Cushing's syndrome. Many of Mrs Horton's physical symptoms were classic features of the syndrome.

Misty Evans

Psychiatric disturbance is not uncommon, and Mrs Horton was at different times to experience sleep disturbance and insomnia, paranoia, depression and agitation, as well as the occasional psychotic episode.

She had never suffered from psychiatric illness before. Her first admission to the Priory had lasted for no more than a few days, but she could not work effectively for the rest of Indeed, she was readmitted to the Priory for a week or so later in November.Mrs Horton had known him socially for many years, but she had never been his patient.

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