Concerns raised by nurses more than 25 years ago about excessive use of powerful painkilling drugs at Gosport War Memorial Hospital were ignored resulting in lives being needlessly cut short, according to a public inquiry into more than 800 deaths at the hospital.
A long-awaited report published today, which highlights the “bravery” of the nurse whistleblowers concerned, shows nursing staff were the first to raise the alarm about the inappropriate prescribing and administration of opioid painkillers but their concerns were dismissed.
However, it also shows nurses were involved in giving the drugs over many years despite the obvious link to deaths and describes numerous failings in overall nursing care.
In all the Gosport Independent Panel – chaired by Bishop of Liverpool James Jones – concluded the lives of more than 450 people had been shortened due to a reckless prescribing regime that showed “a disregard for human life”.
A further 200 patients were likely to have suffered the same fate in the period from 1989 to 2000 amid “a culture of shortening the lives of a large number of patients”, said the panel.
There was an institutionalised regime of prescribing and administering ‘dangerous doses’ of a hazardous combination of medication not clinically indicated or justified
“There was an institutionalised regime of prescribing and administering ‘dangerous doses’ of a hazardous combination of medication not clinically indicated or justified with patients and relatives powerless in their relationship with professional staff,” said the report.
Relatives were also rebuffed and ignored when they tried to raise concerns, said the report which found families were “consistently let down by those in authority”.
It goes on to raise serious concerns about the actions of a wide range of organisations involved in investigating the deaths and conduct of healthcare professionals, including the Nursing and Midwifery Council, which “all failed to act in ways that would have better protected patients and relatives”.
The 387-page report shows a staff nurse was one of the first to express her disquiet about the use of diamorphine and syringe drivers in 1991, raising it with the local branch convenor of the Royal College of Nursing.
Ten nurses went on to attend a meeting where they raised various concerns including the fact not all patients prescribed diamorphine were in pain, the fact no other forms of milder painkiller appeared to be considered and that “patients deaths are sometimes hastened unnecessarily”.
Yet records of this and subsequent meetings, conversations and correspondence show these concerns were by and large swept under the carpet by hospital management.
The documents show that the nurses raised clear concerns in 1991, but these were ignored.
“The documents show that the nurses raised clear concerns in 1991, but these were ignored. From the perspective of 2018, it is hard to understand how such serious matters could be so easily discounted,” said the report.
From February 1991 – when the staff nurse set out her concerns in a letter to the hospital’s patient services manager – to January 1992 the report shows “a number of nurses raised concerns about the prescribing of drugs, in particular diamorphine”.
“In so doing, the nurses involved, supported by their Royal College of Nursing branch convenor, gave the hospital the opportunity to rectify the practice,” said the report.
“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 documents reviewed by the panel “tell a story of missed opportunity and unheeded warnings”, added the report.
It goes on to highlight the “bravery” of the nurses who attempted to raise concerns about the prescribing regime overseen by GP Dr Jane Burton.
There is evidence in the documents that the nurses felt ostracised as a result
“Raising the concerns in the first place was a brave act given the culture at the hospital. There is evidence in the documents that the nurses felt ostracised as a result,” said the report.
“After an unsatisfactory meeting at which the nurses were faced with an intimidating array of other staff, including doctors, the documents show that the nurses were dismissively told to take any future concerns up directly with the doctor whose practice they had reason to challenge.
“This placed the nurses in a position where the only means of pursuing their reservations was to confront, unsupported, an individual in a professionally dominant position.”
However, the report also highlights the “sub-optimal care and lack of diligence by nursing staff in executing their professional accountability for the care delivered”.
While members of the nursing team were the first to draw attention to problems with the pattern of prescribing and the administration of drugs through continuous subcutaneous infusion, the report says nurses were also party to this.
“The records also show that nurses in the hospital administered the drugs and continued to do so for many years, although the link with the pattern of deaths would have been apparent to them,” said the report.
“Within the professional standards which applied at the time, the nursing staff also had a responsibility to intervene and challenge the prevailing practice on the wards.”
The inquiry panel found an overall picture of nursing care that did not live up to professional standards
Beyond the administering of drugs, the inquiry panel found an overall picture of nursing care that did not live up to professional standards and demonstrated “a lack of concern and regard for individuals’ assessed needs”.
This included a “lack of patient-centred care”, poor record-keeping and monitoring of patients, “poor understanding of pain management” and a lack of sensitive end of life care that took patients’ and families’ needs or concerns into account.
“The shortcomings in nursing care extended to passive and inappropriate responses to the needs of patients, particularly at key times such as at hospital admission,” said the report.
“This was particularly evident in patients who had fallen, patients who had expressed distress and patents who were agitated.”
Where concerns were raised about nursing practice, the report is also critical about how these cases were handled by the nursing and midwifery regulator, including an “almost complete lack of communication” with some of the families involved.
Some of the report’s criticisms of the NMC echo the findings of the recent report into the regulator’s handling of fitness to practise cases linked to the Morecambe Bay maternity scandal, which also found the body had failed to treat bereaved families with respect.
Families were not informed when the NMC decided to look into the conduct of nurses in relation to their care of their loved ones
The report shows families were not informed when the NMC decided to look into the conduct of nurses in relation to their care of their loved ones or of the outcome of these investigations.
“From the point of referral to the NMC’s predecessor body – The United Kingdom Central Council for Nursing Midwifery and Health Visiting – in 2000 it would take ten years for the NMC’s preliminary proceedings committee to decline to proceed in respect of all the allegations against the nurses concerned,” said the report.
It says the NMC was “extremely cautious” when it came to not wishing to undermine any other investigations underway at the time and this led to an “excessive delay” in the nurses’ cases being heard.
“The documents also reveal the almost complete lack of communication between August 2002 and June 2010 when the families were told the outcome,” added the report.
“By its own admission, the Nursing and Midwifery Council in that period had been dedicated to maintaining contact with the official bodies involved.”
The NMC said it was clear it had let families down and the way it communicated with some of the families was “unacceptable” and added to their distress.
“I want to pay tribute to the families who have fought for 20 years to understand what happened to their loved ones at Gosport,” said director of fitness to practise, Matthew McClelland. “It’s clear that we and others badly let them down and I am very sorry for the role we have played in that.
“We will now carry out a careful review of the report to see what action we may need to take and what lessons we can learn.”
He added: “While the way we regulate nurses and midwives has changed significantly and improved in recent years, this report is a stark reminder that patients and their families must always be at the heart of what we do.”
A culture of candour is key to ensuring these events are never repeated
Royal College of Nursing chief executive and general secretary Janet Davies said lessons must be learned by the nursing profession as a whole.
“Nursing as a profession must work hard to seek out lessons from Gosport and we expect that approach to be shared by regulators and the health and care system,” she said.
“The report is right to praise the bravery shown by the nurses who raised concerns. It highlights how difficult it can be for nursing staff to challenge the decisions taken by others. A culture of candour is key to ensuring these events are never repeated and the parts of the NHS that fall short in this area must learn from the best.”
Dr David Chilvers, chair of the governing body for NHS Fareham and Gosport Clinical Commissioning Group responded to the report “on behalf of the Portsmouth and south east Hampshire NHS system”.
“The events in the 1980s and 1990s described in the Panel’s report should not have happened, and we are truly sorry that the standard of care provided was entirely unacceptable, and that families were not treated with the dignity and respect they deserved,” he said.
However, he added that “much has changed” since the events took place and Gosport War Memorial Hospital was “a much valued hospital in the local community”.
“This is a detailed report which highlights important lessons for the health service and both the local and the national NHS will have to learn much from the diligent work of the panel members,” he said.
“So the task of all local NHS organisations now – and the debt we owe to those families - is to meticulously review the contents of the report, and to take whatever action is required to prevent such a situation from occurring again.”