450 lives shortened by hospital regime of administering opioids – inquiry
An additional 200 patients were ‘probably’ similarly affected by the practice at Gosport War Memorial Hospital, an independent panel found.
An “institutionalised regime” of prescribing and administering opioids without medical justification at the Gosport War Memorial Hospital shortened the lives of more than 450 people, an inquiry has found.
An additional 200 patients were “probably” similarly affected between 1989 and 2000, when taking into account missing records, according to a report by the Gosport Independent Panel.
Hospital management, Hampshire Police, the Crown Prosecution Service (CPS), General Medical Council (GMC) and Nursing and Midwifery Council (NMC) “all failed to act in ways that would have better protected patients and relatives”, the panel said.
Its report also highlighted failings by healthcare organisations, local politicians and the coronial system.
The Gosport Independent Panel investigation into hundreds of suspicious deaths at the hospital, which was first launched in 2014, examined more than one million pages.
It revealed “there was a disregard for human life and a culture of shortening lives of a large number of patients” at the Hampshire hospital.
The report added: “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 relatives complained or raised concerns, they were “consistently let down by those in authority – both individuals and institutions”.
The report concludes: “The panel found evidence of opioid use without appropriate clinical indication in 456 patients.
“The panel concludes that, taking into account missing records, there were probably at least another 200 patients similarly affected but whose clinical notes were not found.
“The panel’s analysis therefore demonstrates that the lives of over 450 people were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital, and that probably at least another 200 patients were similarly affected.”
The panel found that, over a 12-year period as clinical assistant, Dr Jane Barton was “responsible for the practice of prescribing which prevailed on the wards”.
In 2010, the GMC ruled that Dr Barton, who has since retired, was guilty of multiple instances of professional misconduct relating to 12 patients who died at the hospital.
Nurses on the ward were not responsible for the practice but did administer the drugs, including via syringe drivers, and failed to challenge prescribing, the panel said.
Consultants, though not directly involved in treating patients on the ward, “were aware” of how drugs were administered but “did not intervene to stop the practice”.
The inquiry, led by the former bishop of Liverpool, the Rt Rev James Jones, did not ascribe criminal or civil liability for the deaths.
However it said: “The Secretary of State for Health and Social Care and the relevant public authorities will want to consider the action that now needs to be taken to further investigate what happened at the hospital.
“The Secretary of State will want to ensure that families who believe they were affected by events at the hospital have the support they deserve going forward, and also to consider wider lessons.”
Health Secretary Jeremy Hunt is due to address MPs on the findings of the Gosport inquiry later, and will face questions about the previous investigations and whether charges should now be brought.
Campaigners have called for tough action following the publication of the report.