I have read many distressing reports into care failings by NHS and independent sector providers over the years, but the report of the inquiry into the care provided at Gosport War Memorial Hospital between 1989 and 2000 still shocked me.
How could such disregard for human life be allowed to persist for so long? How could organisations responsible for overseeing healthcare, professional regulators and the police fail to fulfil their responsibilities to protect the public? How could a local MP dismiss the concerns expressed year after year by people he was elected to represent?
Patients’ families showed courage and tenacity in pressing for their relatives’ deaths to be properly investigated, particularly considering the contempt with which many were treated. Those who challenged the way their loved ones were treated were also often dismissed as troublemakers.
One man who became upset when asked for permission to give his mother “the necessary drugs to assist her through at the end” was described as “another weeper” by Dr Jane Barton, the GP whose prescribing practices are believed to have shortened the lives of more than 450 people.
Last week’s On the Pulse, written before the Gosford report was published, reported on calls by the Royal College of Nursing to redefine healthcare as a “safety-critical industry”, like aviation. That would be ideal but difficult to achieve.
“The tragedy still offers lessons that may prevent rogue or incompetent practitioners from harming patients in future”
Aircraft accidents, and even near misses, tend to make headline news even when there are few or no casualties, due to their dramatic and often public nature.
The people whose lives were shortened at Gosport could have filled a jumbo jet, but their deaths took place one at a time, behind closed doors and across more than a decade. In many cases they would not have appeared suspicious even to their families.
Changes in the monitoring of opioids, and in clinical practice and oversight, make it highly unlikely that a situation like Gosport could happen today. However, the tragedy still offers lessons that may prevent rogue or incompetent practitioners from harming patients in future.
A crucial lesson is that families should be listened to when they express concerns – and the earlier the better. A culture in which patients’ and relatives’ concerns are listened to, taken seriously and addressed as soon as they are raised makes an amicable resolution far more likely. But relatives are often nervous about raising concerns, and may not feel able to press when staff say they are busy.
“On a busy ward with too few staff, time isn’t always easy to find”
Being ‘fobbed off’ a few times will turn concern into dissatisfaction, and listening to people who are dissatisfied and de-escalating the situation requires excellent communication and conflict resolution skills. It also takes time, and on a busy ward with too few staff, time isn’t always easy to find.
Listening to one person’s complaint that their mother has not received the care she needs takes time that could be spent providing that care to her or another patient. It is easy to see why health professionals might shy away from such conversations, rather than nipping concerns in the bud.
With 40,000 nurse vacancies in the NHS, it is almost certain that every day many discussions about concerns are avoided until they turn into conflict.
The government, regulators and healthcare providers can express their sympathy and come up with strategies to ensure patients are treated with compassion and relatives are treated with respect, but those strategies will only work if services have safe staffing levels.
Some real action to recruit and train more nurses – and to retain the ones we already have – would be a fitting response to Gosport, and the best 70th birthday present the NHS could have.