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Gosport Hospital Investigation Panel Identifies Catalogue of Failings

View profile for Guy Pomphrey
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An independent panel found more than 450 deaths occurred after patient’s were given powerful painkillers at Gosport War Memorial Hospital.

Why was the panel established?

The panel investigating the hospital looked at deaths from 1987 to 2001. It was found that staff were  administering dangerous amounts of diamorphine through a syringe driver to patients. Fentanyl and morphine amongst other drugs were also administered. The results of this were heavy sedation and even lives being shortened.

The report stated “the skilled, safe and effective use of powerful analgesics and other sedative drugs can have an enormous positive impact on patients’ comfort and well-being. But, used wrongly, they can also cause great harm. In other words, the medication prescribed at the hospital would have been appropriate where that medication in the dosage prescribed and administered was justified by the patient’s condition; that is to say where it was ‘clinically indicated’.” It is evident that Gosport hospital was not administering the drugs safely or correctly.

What were the conclusions?

The Panel’s main findings from its analysis of the documents relating to the prescribing and administering of drugs are as follows:

  • Finding One: Opioid usage without appropriate clinical indication
  • Finding Two: Anticipatory prescribing with a wide range of doses
  • Finding Three: Continuous opioid usage for patients admitted for rehabilitation or respite care
  • Finding Four: Continuous opioids started at inappropriately high doses
  • Finding Five: Opioids combined with other drugs in high doses
  • Finding Six: Few patients survived long after starting continuous opioids
  • Finding Seven: Prescription and administration of drugs contravened guidelines
  • Finding Eight: Occurrence and certification of deaths

What was the health secretary’s response?

In response to the findings, Health Secretary Jeremy Hunt said the "blame culture" in the NHS has to change. "If you are a doctor or a nurse and you see something going wrong - even if you are perhaps responsible for a mistake yourself - the most important thing, the thing that families want if they are bereaved or if they have a tragedy, is to know that the NHS isn't going to make that mistake again," he said. We make it much too hard for doctors and nurses to do that - they are worried that there will be litigation, they will go up in front of the GMC or NMC, the reputation of their unit - in some places they are worried they might get fired, so we do have to tackle that blame culture and turn that into a learning culture."

He was "confident" that procedures and checks were now in place to ensure similar problems - linked to high mortality rates - were identified quickly.

Family members are now urging the Police to carry out a criminal investigation.

Has the Gosford Hospital Scandal affected you?

If you or someone you know has suffered an injury as a result of sub-standard medical care please contact our medical negligence team on 0113 245 8549 or by completing an enquiry form.