Gosport Hospital: 456 Lives Shortened By Unjustified Opioids

Peter Russell

June 20, 2018

The lives of 456 patients were shortened after they were prescribed and given opioids without justification at Gosport War Memorial Hospital in Hampshire between 1989 and 2000, a report has concluded.

The independent panel said that after taking into account missing medical records, there were probably at least another 200 patients similarly affected.

The Health and Social Care Secretary, Jeremy Hunt, described the findings as "truly shocking".

'A Disregard For Human Life'

The Gosport Independent Panel concluded that:

  • There was a disregard for human life and a culture of shortening the lives of a large number of patients

  • There was an institutionalised regime of prescribing and administering 'dangerous doses' of a hazardous combination of medication not clinically indicated or justified, with patients and relatives powerless in their relationship with professional staff

  • When the relatives complained about the safety of patients and the appropriateness of their care, they were consistently let down by those in authority – both individuals and institutions

  • The senior management of the hospital, healthcare organisations, Hampshire Constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) all failed to act in ways that would have better protected patients and relatives, whose interests some subordinated to the reputation of the hospital and the professions involved

The panel, chaired by former Bishop of Liverpool, Rt Rev James Jones, found that over a 12-year period, Dr Jane Barton, a GP working as a clinical assistant, was responsible for the practice of prescribing opioid painkillers on the wards.

Dr Barton faced disciplinary action in 2010 from the GMC over events at the Gosport hospital, although she was not struck off the medical register.

However, the report recognised that at the Gosport hospital, "The practice of anticipatory prescribing, and of administering certain drugs in circumstances and doses beyond what would have been indicated or justified clinically, involved the consultants, the clinical assistant, the nurses and the pharmacists".

Concerns By Nurses And Families Were Ignored

Initial concerns were raised by nursing staff in 1991, over the prescribing and use of drugs with syringe drivers, but these were ignored. Between then and January 1992, a number of nurses raised concerns about prescribing, specifically the prescribing of diamorphine.

Concerns of families of loved ones who had died at the hospital were raised in 1998 but were also sidelined.

In 2000, concerns about prescribing practices in the hospital were brought to the attention of the GMC but there was a 10-year delay before the GMC's Fitness to Practise Panel considered sanctions against Dr Barton, the report said.

In a statement to the Commons, Mr Hunt said "there was a catalogue of failing by the local NHS, Hampshire Constabulary, the GMC, the NMC, the coroners, and a steward of the system, the Department of Health". Mr Hunt promised a fuller response to the report's findings in due course, including "whether criminal charges should now be brought".

In a forward to his report, Bishop Jones wrote that "what has to be recognised by those who head up our public institutions is how difficult it is for ordinary people to challenge the closing of ranks of those who hold power". He added: "It is a lonely place, seeking answers to questions that others wish you were not asking."

In a statement to reporters today, Bishop Jones said: "It is not for the panel to ascribe criminal and civil liability. It will be for any future judicial processes to determine whatever culpability and criticism might then be forthcoming."
 

Reaction to The Report's Findings

Charlie Massey, chief executive of the GMC, said the regulator would be studying the report carefully. "Patients and their families were clearly let down by the system, and that is not good enough," he said.

Rachel Power, chief executive of the Patients Association, said a pressing question was whether events at Gosport could be repeated in today's NHS. "Doctors are some of the most trusted professionals in the country – and rightly so," she said. "But today’s findings will undeniably cause doubt, concern and anxiety for patients who will already be nervous about a health service creaking under the most intense strain it has faced in decades."

Olivia Pinkney, the chief constable of Hampshire Constabulary, said: "We will assess any new information contained within the report in conjunction with our partners in health and the Crown Prosecution Service in order to decide the next steps."

The Gosport Independent Panel Report, 20th June 2018. Report.

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