• 456 patient deaths caused by inappropriate painkillers being prescribed at Gosport War Memorial Hospital
  • New report finds ’instutionalised practice of shortening patients’ lives’ at the hospital
  • Local health organisations, police, and regulators all failed to step in

More than 450 patients died from prescriptions made “without medical justification” at a hospital where the use of opioids resulted in an “institutionalised practice of shortening patients’ lives”, an investigation has found.

At least 200 other patients probably had their life shortened as a “direct result” of the prescribing and administration of opioids that “became the norm” at Gosport War Memorial Hospital, it said.

The deaths occurred in the 1990s and early 2000s, and the total is higher than the number of patients killed by Dr Harold Shipman, who was convicted in January 2000.

Opioids are painkillers that can be beneficial to patients but can be a risk to their health when used inappropriately.

Most of the patients who died were being treated for rehabilitation and respite care.

The Gosport Independent Panel examined the records of 1,564 patients who died at the hospital between 1987 and 2001. A total of 456 patients died as a result of the drugs being administered without medical justification. 

Among the panel’s findings were:

  • Disregard for human life and a culture of shortening the lives of a large number of patients;
  • An institutionalised regime of prescribing and administering “dangerous doses” of medication;
  • Patients and relatives who raised concerns were “let down by those in authority”.

No one has been charged with criminal offences, but now-retired GP Jane Barton was responsible for the practice of prescribing on the wards.

Concerns about her were raised to the General Medical Council in 2003, but it took seven years before the GMC found her guilty of prescribing “potentially hazardous” levels of drugs to patients.

Despite this she was not struck off, despite the GMC recommending her erasure from the register to its fitness to practice panel. Consultants and nurses were aware of how the drugs were being prescribed, but did not intervene or challenge the practice.

One group of nurses did raise concerns about the hospital’s prescribing practices between February 1991 and January 1992, but their “warnings went unheeded” which resulted in more patients dying.

Those nurses subsequently felt “ostracised”, the panel said.

It is not the panel’s job to ascribe criminal or civil liability.

However, it found that the hospital management, local healthcare organisations, Hampshire Constabulary, the Crown Prosecution Service, the General Medical Council, the Nursing and Midwifery Council, and local politicians “all failed” to act to protect patients and their families.

Local healthcare organisations and the police were “defensive” and denied there were problems with services at the hospital to families, the media, and to other NHS organisations.

Some of the above organisations were more interested in the reputation of the hospital and professions involved.

The families, and “nation as a whole”, are entitled to ask how the events could have happened, the report said.

The panel is calling on health secretary Jeremy Hunt, home secretary Sajid Javid, the Attorney General, head of Hampshire Police, and “relevant investigative authorities” to “recognise the significance” the report, and “act accordingly”. 

Mr Hunt told Parliament today there was a ”catalogue of failures” at the hospital, and other relevant organisations which included the Department of Health and Social Care.

He said new measures had put in place since the deaths occurred, such as the Duty of Candour, Care Quality Commission inspections, and the establishment of medical examiners next year. 

The government will make its full response to the Inquiry in autumn, Mr Hunt said.  

The £14m inquiry was led by Bishop James Jones, who previously chaired the Hillsborough Independent Panel.

It was set up four years ago by former health minister Norman Lamb.

Speaking at Prime Minister’s Questions this afternoon Mr Lamb said the findings were “truly shocking”, and called for a police investigation by a police force outside Hampshire. 

Prime Minister Theresa May apologised for the length of time it took families to get answers.

The panel included nursing expert Prof Deborah Sturdy, barrister Kate Blackwell QC, geriatric medicine specialist Dr Colin Currie, investigative journalist David Hencke, former Scotland Yard commander Duncan Jarrett, pharmacist Prof Jim Smith, information expert Christine Gifford, elderly care specialist Dr John Pounsford and medical expert Dr Bill Kirkup.

Today the hospital, run by Southern Health Foundation Trust, provides a 20-bed GP ward, outpatient services (staffed by Portsmouth Hospitals Trust), a rapid assessment unit, and community care team led clinics.

Charlie Massey, chief executive of the General Medical Council, said patients and families had been “let down by the system”, and that the organisation would study the report “carefully” to identify learning points.” 

“We are committed to taking any further action necessary in light of information revealed by this report.”

Matthew McClelland, director of fitness to practice at the Nursing and Midwifery Council, said it was “clear that we and others badly let [patients and families] down, and I am very sorry for the role we have played in that. 

“We know our communications with some of the families was unacceptable, and for some of those who lost loved ones, we added to their distress.”

He said a “careful review” of the report would be carried out to see what lessons should be learned.  

Olivia Pinkney, chief constable of Hampshire Police, said its three police investigations into the hospital between 1998 and 2006 resulted in evidence presented to the Crown Prosecution Service and Treasury Counsel, which concluded there was not enough evidence to proceed. 

”We will assess any new information contained within the report in conjunction with our partners in health and the CPS in order to decide the next steps,” she said.

Article updated at 10.45am on 21 June to include responses from the GMC, NMC, and Hampshire Police.