NHS must learn from 'catalogue of failures' behind Gosport deaths, says Hunt

Jeremy Hunt has apologised for the deaths of more than 450 patients killed by inappropriate prescribing of opioids at an NHS hospital and warned that the health service must ensure changes implemented since would prevent a similar incident in future.

Health and social care secretary Jeremy Hunt (Photo: Pete Hill)
Health and social care secretary Jeremy Hunt (Photo: Pete Hill)

The health and social care secretary's comments came after the publication on Wednesday of a report by an independent panel set up to investigate events at the Gosport War Memorial Hospital between 1987 and 2001.

The report found that '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 or justified.'

The report found that a GP employed as a clinical assistant at the hospital, Dr Jane Barton, oversaw the prescribing regime. 'Over a 12-year period as clinical assistant, Dr Barton was responsible for the practice of prescribing which prevailed on the wards,' the report said.

Prescribing

It also found, however, that 'although the consultants were not involved directly in treating patients on the wards, the medical records...show that they were aware of how drugs were prescribed and administered but did not intervene to stop the practice'.

Relatives who raised concerns about the safety of patients at the hospital 'were consistently let down by those in authority – both individuals and institutions', the report found.

'These included the senior management of the hospital, healthcare organisations, Hampshire Constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and the Nursing and Midwifery Council. 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.'

Bishop James Jones, who led the inquiry, said: 'The documents reveal at Gosport War Memorial Hospital from 1989 to 2000 an institutionalised practice of the shortening of lives through prescribing and administering opioids without medical justification.'

Patient deaths

Bishop Jones said that records seen by the inquiry panel showed that '456 patients died through prescribing and administering opioids without medical justification' and that 'taking into account missing records there were probably 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'.

In a statement in parliament, Mr Hunt apologised for the deaths on behalf of the NHS and the government, warning that 'had the establishment listened when junior NHS staff spoke out, ahd the establistment listened when ordinary families spoke out rather than treating them as troublemakers, many of those deaths would not have happened'.

The health and social care secretary said: 'I also want to reassure the public that important changes have taken place since these events which would make the catalogue of failures listed in the report less likely. These include the work of the CQC as an independent inspectorate with a strong focus on patient safety, the Learning from Deaths programme and establishment of medical examiners across NHS hospitals from next April.

'But today’s report shows we still need to ask ourselves searching questions as to whether we have got everything right and we will do that as thoroughly and quickly as possible when we come back to the House with our full response.'

Mr Hunt added that 'the police, working with the CPS and clinicians as necessary, will now carefully examine the new material in the report before determining their next steps – in particular whether criminal charges should be brought'.

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