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Gosport hospital: more than 450 patients died due to opioid drugs policy Gosport hospital: more than 450 patients died due to opioid drugs policy
(35 minutes later)
More than 450 patients died and possibly 200 more had their lives shortened because of a Hampshire hospital’s practice of giving opioid drugs without medical justification, a major inquiry has found.More than 450 patients died and possibly 200 more had their lives shortened because of a Hampshire hospital’s practice of giving opioid drugs without medical justification, a major inquiry has found.
The independent report found that Dr Jane Barton, the GP who ran wards at Gosport War Memorial hospital, routinely overprescribed drugs for her patients in the 1990s. Consultants were aware of her actions but did not intervene.The independent report found that Dr Jane Barton, the GP who ran wards at Gosport War Memorial hospital, routinely overprescribed drugs for her patients in the 1990s. Consultants were aware of her actions but did not intervene.
The inquiry, led by the bishop of Liverpool, James Jones, found that 456 patients died because of the drugs. A further 200 patients may have had their lives shortened, but their records are missing.The inquiry, led by the bishop of Liverpool, James Jones, found that 456 patients died because of the drugs. A further 200 patients may have had their lives shortened, but their records are missing.
The report said senior nurses were worried about using diamorphine – the medical name for heroin – for patients who were not in pain, administered through a syringe-driver pumping out doses that were not adjusted for the individual’s needs. The report said senior nurses were worried about using diamorphine – the medical name for heroin – for patients who were not in pain, administered through a syringe-driver pumping out doses that were not adjusted to each patient’s needs.
Concerns were raised as early as 1988. In 1991, a staff meeting was held that was attended by a convenor from the Royal College of Nursing. Concerns were raised as early as 1988. In 1991, a staff meeting was held that was attended by a convenor from the Royal College of Nursing. But the nurses were warned not to take their concerns further. They had, the report said, given the hospital the opportunity to rectify the overprescribing.
But the nurses were warned not to take their concerns further. They had, the report said, given the hospital the opportunity to rectify the over-prescribing.
“In choosing not to do so, the opportunity was lost, deaths resulted and 22 years later, it became necessary to establish this panel in order to discover the truth of what happened.”“In choosing not to do so, the opportunity was lost, deaths resulted and 22 years later, it became necessary to establish this panel in order to discover the truth of what happened.”
The panel made it clear it thought prosecutions should follow, although it was beyond its remit to say so.The panel made it clear it thought prosecutions should follow, although it was beyond its remit to say so.
“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,” Jones said in the introduction to the report.
“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’.”
“It is a lonely place, seeking answers to questions that others wish you were not asking.”
The report invited the health secretary, the attorney general, the chief constable of Hampshire police and the relevant investigatory authorities “to recognise the significance of what is revealed about the circumstances of deaths at the hospital and act accordingly”.The report invited the health secretary, the attorney general, the chief constable of Hampshire police and the relevant investigatory authorities “to recognise the significance of what is revealed about the circumstances of deaths at the hospital and act accordingly”.
Barton worked as a clinical assistant at the hospital for 12 years. She was responsible for prescribing on the wards, but her superiors, the hospital’s consultants, knew what she was doing.Barton worked as a clinical assistant at the hospital for 12 years. She was responsible for prescribing on the wards, but her superiors, the hospital’s consultants, knew what she was doing.
Nurses had a responsibility to challenge Barton if they thought the drugs were not in the interests of the patients, but records showed they did not exercise it, the report said.Nurses had a responsibility to challenge Barton if they thought the drugs were not in the interests of the patients, but records showed they did not exercise it, the report said.
The documents “also demonstrate the suboptimal care and lack of diligence by nursing staff in executing their professional accountability for the care delivered”, the panel found.The documents “also demonstrate the suboptimal care and lack of diligence by nursing staff in executing their professional accountability for the care delivered”, the panel found.
The patients and their families – who the report said had shown “remarkable tenacity and fortitude in questioning what happened to their loved ones” – were failed by numerous inquiries and investigations over many years. The report criticised healthcare organisations, the limited police investigations and the processes of the General Medical Council.The patients and their families – who the report said had shown “remarkable tenacity and fortitude in questioning what happened to their loved ones” – were failed by numerous inquiries and investigations over many years. The report criticised healthcare organisations, the limited police investigations and the processes of the General Medical Council.
In 2009, Barton appeared before a disciplinary tribunal of the GMC, the doctors’ regulatory body, where she was heavily censured and conditions placed on her practice. The GMC later said it was wrong not to strike her from the medical register.In 2009, Barton appeared before a disciplinary tribunal of the GMC, the doctors’ regulatory body, where she was heavily censured and conditions placed on her practice. The GMC later said it was wrong not to strike her from the medical register.
In a statement, Jones, who also led the Hillsborough inquiry, said: “Families will ask: how could this practice continue and not be stopped through the various police, regulatory and inquest processes? The panel’s report shows how those processes of scrutiny unfolded and how the families were failed.”In a statement, Jones, who also led the Hillsborough inquiry, said: “Families will ask: how could this practice continue and not be stopped through the various police, regulatory and inquest processes? The panel’s report shows how those processes of scrutiny unfolded and how the families were failed.”
Diamorphine was the main life-shortening opioid drug given to patients, often in a syringe-driver, which was attached to the patient’s back and ensured a constant dosage. The report tells of the testimony of Pauline Spilka, a nurse who gave evidence to the Hampshire police in 2001 during their inquiries. She said she had never heard of a syringe-driver before she worked at Gosport. Diamorphine was the main life-shortening opioid drug given to patients, often in a syringe-driver, which was attached to the patient’s back and ensured a constant dosage. The report recounts the testimony of Pauline Spilka, a nurse who gave evidence to the Hampshire police in 2001 during their inquiries. She said she had never heard of a syringe-driver before she worked at Gosport.
She later learned that it was used to give drugs to seriously ill patients. “It was also clear to me that any patient put on to a syringe-driver would die shortly after,” she told police at the time. “During the whole time I worked there I do not recall a single instance of a patient not dying having been put into a driver.” She later learned it was used to give drugs to seriously ill patients. “It was also clear to me that any patient put on to a syringe-driver would die shortly after,” Spilka told police at the time. “During the whole time I worked there I do not recall a single instance of a patient not dying having been put into a driver.”
She was deeply troubled, she said, by the case of one man aged about 80 who had stomach cancer but was lively and able to wash and look after himself. “One day I left work after my shift and he was his normal self. Upon returning to work the following day I was shocked to find him on a syringe-driver and unconscious.” He was unconscious until he died, she said. She felt unable to speak to his family, convinced the death had been unnecessary.She was deeply troubled, she said, by the case of one man aged about 80 who had stomach cancer but was lively and able to wash and look after himself. “One day I left work after my shift and he was his normal self. Upon returning to work the following day I was shocked to find him on a syringe-driver and unconscious.” He was unconscious until he died, she said. She felt unable to speak to his family, convinced the death had been unnecessary.
Opioid drugs are used to relieve severe pain. The medical notes were poor but in 456 cases there was no evidence the opioids were justified.Opioid drugs are used to relieve severe pain. The medical notes were poor but in 456 cases there was no evidence the opioids were justified.
The report spoke of “anticipatory prescribing”, which can be used to ensure patients get pain relief when they need it. But in Gosport, records show anticipatory prescribing “in a very wide dose range” with no specified trigger for the start or the end of it.The report spoke of “anticipatory prescribing”, which can be used to ensure patients get pain relief when they need it. But in Gosport, records show anticipatory prescribing “in a very wide dose range” with no specified trigger for the start or the end of it.
“In some, prescribing was done on the day of admission of patients not admitted for end-of-life care,” said the report. This was contrary to guidance at the time.“In some, prescribing was done on the day of admission of patients not admitted for end-of-life care,” said the report. This was contrary to guidance at the time.
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