I was on holiday last week and it was with an element of dread that I started to see the name Gosport War Memorial Hospital mentioned in the national media and then, on checking my emails, a wave of press releases coming through about it.
The inquiry panel that looked into over 800 deaths at the hospital between 1989 and 2000 concluded the organisation had a “culture of shortening the lives of a large number of patients”.
It highlighted that nurses were involved in the inappropriate prescribing and administration of opioids over many years, despite having a “responsibility to intervene and challenge the prevailing practice on the wards”.
“The panel also found that nursing staff were the first to raise the alarm”
However, at the same time, the panel also found that nursing staff were the first to raise the alarm – although unsuccessfully.
A staff nurse called Anita Tubbritt 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 of the Royal College of Nursing.
Ten nurses went on to attend a meeting where they raised various concerns including the fact that not all patients prescribed diamorphine were in pain, that no milder painkillers appeared to be considered and that “patients’ deaths are sometimes hastened unnecessarily”.
Yet records of this and subsequent meetings, conversations and correspondence show that the nurses’ concerns were by and large swept under the carpet by hospital management. The documents reviewed by the panel “tell a story of missed opportunity and unheeded warnings”, states the report.
The Gosport case has obvious echoes of past scandals such as Mid Staffs and Morecambe Bay, but also those before them. Once again, it raises the question of how this was allowed to happen – and it could have been ignored for so long.
Why were the concerns of some nurses and other clinicians ignored? Why did others feel they could not raise any concerns at all? And why was it left to a staff nurse to try to act on behalf of patients, while more senior nurses seemingly stood by?
These issues are precisely why Nursing Times launched the Speak Out Safely campaign in 2013, with a call to employers “to encourage any staff member who has a genuine patient safety concern to raise this at the earliest opportunity”.
“I really hope the NHS and healthcare more widely are in a different place now”
Nearly 100 NHS providers signed up to support a pledge backing this aim, as did many other NHS and independent healthcare organisations.
The only solace I can take from the Gosport report is that most of the events documented in it took place 20 years ago or more and I really hope the NHS and healthcare more widely are in a different place now.
My fear, however, is that they are not and that, a few years down the line, I will once again read a similar report with a similar feeling of sadness.
While the report highlights the “bravery” of individuals like Ms Tubbritt for coming forward with their concerns, strength often comes from togetherness. The more people stand together and support each other, the less likely it is that their concerns can be dismissed or ignored.