At least 456 patients died after being given opioids ‘without medical justification’ at a Gosport hospital where ‘there was a disregard for human life,’ a major report has found.
Another 200 ‘probably’ had their lives shortened at Gosport War Memorial hospital as a direct result of the prescribing the drugs without justification.
On the day the Gosport Independent Panel’s report was published, Bishop James Jones said there was an ‘institutionalised practice of shortening lives through prescribing and administering opioids without medical justification at the hospital’.
Rt Rev Jones has now called on Hampshire police’s chief constable, the home secretary Sajid Javid and health secretary Jeremy Hunt to ‘act accordingly’.
Retired GP Dr Jane Barton, who was at the time clinical assistant on the wards, was ‘responsible for the practice of prescribing which prevailed on the wards,’ the bishop said.
But he said it was ‘not for the panel to ascribe the criminal or civil liability’.
Subsequent police investigations, and those carried out by other authorities, have been criticised.
In his foreword the bishop said senior hospital management, healthcare organisations, Hampshire police, local politicians, the coronial system, Crown Prosecution Service, the General Medical Council and the Nursing Midwifery Council had all ‘failed’.
He said: ‘All failed to act in ways that would have been better protected patients and relatives, whose interests some subordinated to the reputation of the hospital and the professions involved.’
The panel found 456 patients died linked to prescribing opioids via analysis of medical records, with ‘at least another 200 patients whose lives were shortened ‘as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital,’ the bishop said.
Families of those who died were ‘failed by the professional bodies and by others in authority’ charged with regulating the practice of professionals, the report said.
Rt Rev Jones’s foreword to the report added: ‘During a certain period at Gosport War Memorial Hospital, there was a disregard for human life and a culture of shortening the lives of a large number of patients by prescribing and administering “dangerous doses” of a hazardous combination of medication not clinically indicated of justified.’
In his statement Rt Rev Jones added: ‘The documents seen by the panel for a 12-year period a clinical assistant, Dr Barton was responsible for the practice of prescribing which prevailed on the wards.’
Consultants were aware but ‘did not intervene to stop the practice,’ he added.
The report said documents reveal ‘a story of missed opportunities and unheeded warnings’.
The pattern of deaths showed a ‘marked increase’ from 1993, peaking in 1998 before a sharp decrease ‘to resume the previous annual level by 2001.
Concerns were raised as early as February 1991, with staff nurses, praised for their bravery, ‘expressing concern over the prescribing and administration of drugs with syringe drivers’.
But the bishop pointed to shortcomings, adding: ‘Nurses had a responsibility to challenge prescribing where it was not in the interests of the patient. The records show that nurses did not discharge that responsibility and continued to administer the drugs prescribed.’
The bishop added: ‘The panel now calls upon the secretary of state for health and social care, the home secretary, attorney general and the chief constable of Hampshire police and the relevant investigative authorities to recognise the significance of what is revealed about the circumstances of deaths at the hospital and to act accordingly.’
The Gosport Independent Panel, led by Bishop James Jones, was set up in 2014 and had been expected to report in December last year.