Sedative erro ors missed by trust

A Hampshire trust has been condemned after failing to uncover the over-prescription by doctors of powerful pain-killers and sedatives to vulnerable elderly patients.

The Commission for Health Improvement launched an investigation last October into care at Gosport War Memorial Hospital - then run by Portsmouth Healthcare trust - between 1998-2001.

The subsequent report, out last week, said the trust had made a catalogue of mistakes which had put patients 'at risk'.

Most importantly, CHI said it had failed to undertake an immediate review of prescribing practice back in 1998 despite a series of police investigations into the deaths of its patients and clues from a pattern of patient complaints, as well as information from pharmacy data. The commission also found there was no system for supervising the performance of GPs working as clinical assistants who had a crucial role in the administration of drugs.

CHI director of nursing Liz Fradd said that because of the inadequacies of assessment on admission, some elderly patients who needed rehabilitation care were given drugs under the 'Wessex guidelines' which were meant to be used for terminally ill patients. Two wards - Daedalus and Dryad - had been worst affected by the 'excessive' use of pain relieving and sedative drugs.

But CHI stressed that it could not determine whether patients died as a result of the hospital's care. CHI chief executive Peter Homa said:

'Portsmouth Healthcare trust failed to have appropriate systems in place in 1998 to monitor the practice of some staff at Gosport War Memorial Hospital. It failed to recognise a potential risk to patients, many of whom were frail older people, from the levels of analgesia being prescribed. As a result, it did not carry out a proper review of prescribing and excessive medication wasn't questioned.'

So far an unspecified 'number' of doctors and nurses working at the hospital have been referred to the relevant regulatory bodies - the General Medical Council and the Nursing and Midwifery Council.

But no action has been taken against senior managers responsible for the clinical governance systems in place between 1998-2001.

Ms Fradd stressed that the role of individuals in what happened at Gosport were outside the scope of the CHI inquiry but that the executive board were ultimately accountable.

CHI said it had no concerns over standards at the hospital today. In February this year, Hampshire police decided not to continue their investigation into the patient deaths following advice from the Crown Prosecution Service that there were no grounds on which to proceed.

Fareham and Gosport primary care trust, which since April took over the running of the hospital, said it fully accepted the report's findings and promised to implement the recommendations in full.

Hampshire and Isle of Wight strategic health authority chief executive Gareth Cruddace said the SHA was not contemplating any further action against individuals or groups of individuals, other than the reviews by professional bodies currently underway.

www. chi. nhs. uk