The Gosport Independent Panel has concluded that the lives of a large number of patients were shortened by administering “dangerous doses” of medication between 1986 and 2000 at Gosport War Memorial Hospital.
The Panel concluded that during this period the medication that was prescribed was not clinically indicated or justified. The Panel’s analysis demonstrates that “the lives of very many people were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital.”
Concerns at the hospital were first raised by nurses over 27 years ago. The families of the victims have been seeking justice for at least twenty years. The families have pleaded that “the truth must now come out”.
The Panel found evidence of “opioid use without appropriate clinical indication in 456 patients. The Panel’s analysis, therefore, demonstrated 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.”
“During the period between 1989 and 2000 at Gosport War Memorial Hospital, which appears to cover the start and end of the pattern of opioid prescribing of concern, the disclosed documents reveal 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 report states that “there is no evidence available to the panel to suggest that either the pharmacists or Portsmouth healthcare NHS Trust’s Drugs and Therapeutics Committee challenged the practice of prescribing which would have been evident at the time.”
“Pharmacist visits to the hospital continued twice a week and included checks on ward stocks and examinations of patients’ drug charts. The system was primarily aimed at maintaining adequate supplies, but there was also a mechanism for raising concerns.”
Chairman of the panel the Right Reverend James Jones KBE commented:
“The shocking outcome of the Panel’s work is that we have now been able to conclude that the lives of over 450 patients were shortened while in the hospital and to demonstrate that those first families were right to persist in asking questions about how their loved ones had been treated.
“It is a lonely place, seeking answers to questions that others wish you were not asking. That loneliness is heightened when you’re made to feel even by those close to you that it’s time to get over it and to move on. But it is impossible to move on if you feel that you have let down someone you love and that you might have done more to protect them from the way they died. Many of the families to whom the Panel has listened feel a measure of guilt, albeit misplaced.
“The anger is also fuelled by a sense of betrayal. Handing over a loved one to a hospital, to doctors and nurses, is an act of trust and you take for granted that they will always do that which is best for the one you love. It represents a major crisis when you begin to doubt that the treatment they are being given is in their best interests. It further shatters your confidence when you summon up the courage to complain and then sense that you are being treated as some sort of ‘troublemaker’.
“This Report is a vindication of their tenacious refusal to be dismissed. It shows how they were failed by the professional bodies and by others in authority charged with responsibility for regulating the practice of professionals in the interests of patient safety.”