- How did more than 450 patients die and possibly 200 more have their lives shortened by being given lethal doses of painkilling drugs at a UK hospital.
- How did it happen over such a long period of time – 11 years – without being stopped?
- How did it even happen more than once, never mind hundreds of times?
The review into deaths at Gosport War Memorial Hospital today concluded that there was a “disregard for human life” of a large number of patients from 1989 to 2000.
Can there be a more despairing and saddening description of any UK health service?
Dr Jane Barton, the GP and clinical assistant who ran wards where opioid drugs were routinely overprescribed for patients, is of course the focus of media coverage today, as calls are made for criminal proceedings to be opened.
We cannot, however, let this become a case where the entire focus is placed entirely on a single doctor. The recriminations of this scandal must run far deeper, right across the all organisations and bodies which at each stage failed to challenge what was happening, and protect lives.
Anything less will simply leave the door open to this large scale loss of life happening in our health service again.
Report places hospital, Police, CPS, General Medical Council and Nursing and Midwifery Council under scrutiny
The report says hospital management, Hampshire Police, the Crown Prosecution Service (CPS), General Medical Council (GMC) and Nursing and Midwifery Council (NMC) each ‘failed to act in ways that would have better protected patients and relatives”.
We are not talking about individuals, we are talking many, many people who failed to stand up and be counted for patients.
It says concerns about an ‘institutionalised regime’ of prescribing and administering dangerous’ amounts of a medication not clinically justified were first raised as early as 1988.
Senior nurses were worried about using diamorphine for patients who were not in pain and giving doses that were not adjusted for the individual’s needs.
Consultants were also aware of what was happening, but did not intervene, and nurses were warned not to take their concerns further though – an opportunity to rectify the over-prescribing which was missed, the report says.
Such an environment should never be able to develop in any walk of life, least of which the health service, where the questioning and scrutiny of people in senior roles must not only be accepted, but encouraged to ensure complete transparency and learning at all times.
Of course, the failings have not been limited to the hospital itself.
Police previously investigated the deaths of 92 patients during three inquires between 1998 and 2006, but no prosecutions were brought. The panel said the quality of the force’s three investigations was “consistently poor” and that officers had a mindset of seeing family members who complained as “stirring up trouble”.
However, files were passed to the Crown Prosecution Service (CPS) about the deaths of elderly patients at the hospital in February 2005, but the CPS said negligence could not be proven to a criminal standard and that there was no realistic prospect of conviction of healthcare staff.
Still lives were being avoidably lost, and it was only when in 2009 that an inquest jury ruled that drugs given to five elderly people at the hospital contributed to their deaths, that action was taken.
The GMC then found Dr Barton guilty of serious professional misconduct, highlighting a catalogue of failings, including issuing drugs which were “excessive, inappropriate and potentially hazardous’.
Despite this, she was not struck off – a decision the GMC has since admitted was wrong – meaning she was able to simply retire from medical practice.
In August 2010, the CPS announced no criminal charges were to be brought against Dr Barton after finding insufficient evidence to mount a prosecution for gross negligence manslaughter in 10 key cases.
Organisations ‘may have acted in own interests – motivated by reputation management’
There are some quite shocking comments in today’s report, in particular the fact that from 1998 onwards a number of organisations had knowledge of ‘at least part of the picture’ of what was going on.
It adds they ‘may have acted in its own interests and those of its leaders, motivated by reputation management, career self-preservation and taking the path of least resistance’. Truly appalling.
The bishop of Liverpool, James Jones, who led the review, found that 456 patients died because of the drugs. A further 200 patients may have had their lives shortened, but their records are missing – another example of systematic failure and lack of accountability and transparency.
The report has 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”.
Bishop 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?
These questions must be answered fully if such a scandal and avoidable loss of life is to be prevented from happening again.