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Gosport Independent Panel Report

A summary for the LIN

February 2019

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• Community hospitals vary considerably, as they have adapted to the needs of their local populations

• In community hospitals, medical care is normally led by GPs in liaison with consultants, nursing and other health professionals as required

• The pride of local people and their attachment to Gosport War Memorial Hospital was illustrated by the successful campaign to save it from closure in the 1990s and indeed its redevelopment in 1994

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Gosport War Memorial Hospital

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In February 1991 staff at Gosport expressed concern about the prescribing and administration of drugs with syringe drivers. A number of nurses raised concerns about the prescribing of drugs, in particular diamorphine. “A Staff Nurse at the hospital rang the local branch convenor of the Royal College of Nursing to express concerns shared by other members of the night staff over the use of diamorphine and syringe drivers.”

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Concerns raised in 1991

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The concerns

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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. 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.

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Culture

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• It is over 27 year since nurses at the hospital first voiced their concerns

• The report of the Gosport Independent Panel has now (in 2018) shown that the concerns were valid

The lives of over 450 people (and probably another 200 as well) were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital

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Gosport Independent Panel

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“For example, the daughter of one patient discovered that a syringe driver had been inserted. She queried this because she knew her father wasn’t in pain and didn’t need it, but ward staff were dismissive, telling her she was not a nurse and that they were the professionals. She was furious and called her father’s GP, who arranged for the syringe driver to be taken out and for her father to come home.”

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Patient stories

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“A man admitted for dementia was started on a diamorphine syringe driver. Staff asked his son for permission and he gave it but felt there was no explanation of what it meant to be given diamorphine. The dose was doubled, and his father died five days later. His son felt that the diamorphine effectively killed him”.

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Patient stories

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The panel’s findings

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Opioids without indication

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Deaths at the hospital

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Deaths due to bronchopneumonia

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Correlation

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The practice of anticipatory prescribing, and of administering certain drugs in circumstances and doses beyond what would have been indicated or justified clinically, involved the consultants, the clinical assistant, the nurses and the pharmacists.

Many people were prescribed and administered drugs that were not clinically indicated, in quantities sufficient to shorten their lives

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How did this happen?

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1. Anticipatory prescribing was used on the basis that medication might become necessary at a time when the doctor covering a ward was unable or unwilling to attend in order to prescribe it.

2. A pattern of clinical judgements were made that patients were close to death, regardless of the purpose of their admission or the plan in place. The documents show that these judgements were often not justified clinically and did not take into account patients’ or families’ views.

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Why did this happen?

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“It was some while later that I was to learn that all patients upon their admission were written up (by the doctor) who authorised the use of a syringe driver if appropriate. This enabled any member of the nursing staff to set up a syringe driver for a patient without any further reference to the doctor.”

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One account from staff

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If one of the trained members of nursing staff considered that a patient required the use of a syringe driver then they would seek the approval of another trained nurse. Having reached agreement then the driver would be set up. I have witnessed disagreements between nurses where one of them did not agree that a patient required the use of a syringe driver. These disagreements would be resolved by the nurse requiring the syringe driver approaching a more senior nurse and obtaining their consent. I have never known of a case where a staff member did not obtain permission to use a syringe driver from senior staff.

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One account from staff

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The culture at the hospital was a legacy of the concept of ‘clinical freedom’. In theory, this should have been entirely supplanted by evidence-based practice. There should have been an accepted practice of challenge, but this was not the prevailing culture. Indeed, in accepting the medical judgement made most often by the clinical assistant, the consultants effectively supported rather than challenged the practice of prescribing and the nurses were themselves involved.

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Culture

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Pharmacy services Pharmacy services to the hospital were provided under a SLA with the Health Authority. This included the procurement and supply of medicines required, together with advice on their use, security and custody - relationship described as ‘remote’

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Police Health Authority Primary Care Group and Trust Department of Health General Medical Council Nursing and Midwifery Council “No external organisation was able to intervene effectively”

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Investigations

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“Each organisation may have acted in its own interests and those of its leaders, motivated by reputation management, career self-preservation and taking the path of least resistance.” “The tendency of individuals in organisations, when faced with serious allegations [is] to handle them in a way that limits the impact on the organisation and its perceived reputation.”

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Flawed investigations

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A perception rapidly took root with both the police and NHS bodies external to the Trust that Dr Barton might be a ‘rogue doctor’ or ‘lone wolf’, operating surreptitiously and without authorisation. The police focused on the allegation that Dr Barton was guilty of unlawful killing, rather than pursuing a wider investigation

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Another Shipman?

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“Organisations simply do not listen to what their frontline staff have to say. This is despite the fact that those members of staff see what is happening very clearly and can gauge its impact in practice, not least from engaging with members of the public, in this case patients and relatives.”

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Take home messages

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“If those responsible for the hospital had listened properly to what their own nurses said in 1991, and acted, the Panel is clear that the events described in this Report would not have followed the path they did. This should serve as a challenge to all those in positions of authority.”

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Take home messages

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1 Poor systems of scrutiny – by internal and external organisations • Disconnect between two hospitals (supplier and provider): diamorphine use doubled without questions raised by supplier • Lack of monitoring and governance around prescribing of CDs • 2 Poor leadership and poor governance in each organisation (i.e. the supplying hospital, the commissioners, the service provider, the police, and regulators) • No ownership of the risk Concerns not fully investigated (poor investigation ability and processes) & Recommendations not implemented – there appeared to be a lack of drive to implement pathways and guidance. 3 Culture in both commissioner and provider bodies did not focus on patient care but instead focused on protecting organisation and clinicians • Response to complaints centred on protecting reputation of organisations and professionals, rather than on protecting patients • Culture of not asking the right questions (or the difficult questions) - e.g. the Board and chief clinicians did not act on concerns of over-usage of CDs • Professional bias Staff concerns ignored / suppressed & Families distrust of hospital staff ignored

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Key themes

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4 No process for joining up concerns and taking action to prevent further harm • Agencies and regulatory bodies did not share concerns or engage with each other (e.g. Chief Pharmacist, Nursing , Police and other investigators did not share information with each other in order to join up concerns and address risks 5 Unsafe prescribing not identified and challenged • There was a culture of accepted practice and the norm was difficult to change • Prescribers working in isolation • Unnecessary anticipatory prescribing – dangerous doses of opiates

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Key themes

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1. Listening to patients, families and staff 2. Ensuring care is safe 3. Identifying and addressing problems in

care

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Department of Health and Social Care Recommendations

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Discuss and agree what, if any, systems are now in place to prevent this from happening to protect patients and families

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Key questions

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Where can we make improvements (reflect on your own organisation) to identify any irregularities?

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Key questions