Gosport hospital deaths review found nurses’ warnings about opioids went unheeded

Review into hundreds of untimely deaths said night duty nurses were stifled when they spoke up
Gosport War Memorial Hospital

Review into hundreds of untimely deaths said night duty nurses were stifled when they spoke up

Picture: Alamy

If a group of nurses had been listened to the untimely deaths of 456 patients at Gosport War Memorial Hospital in Hampshire could have been avoided, a report said.

Today’s Gosport Independent Panel report hundreds of suspicious deaths at the hospital found a further 200 people's lives might have been cut short, but missing records make full investigations difficult.

The inquiry was launched in 2014 in response to deaths due to opioids being administered without medical justification.

‘Hospital’s culture of shortening lives’

The panel concluded there was ‘a disregard for human life and a culture of shortening lives of a large number of patients’ at the hospital between 1989 and 2000.

The report said a small group of night shift nurses were the first to raise concerns about the overuse of diamorphine and syringe drivers at the hospital in 1991. But their worries were not acted on by the hospital.

‘There is evidence in the documents that the nurses felt ostracised as a result,’ the report reads.

The nurses were told in a meeting to take any future concerns they had directly to those whose practice they were challenging. These individuals included clinical assistant Jane Barton, the only professional yet to face disciplinary action.

The report notes this instruction effectively stopped the nurses in their tracks – and that if the hospital had responded to the nurses’ concerns appropriately, lives could have been saved.  

‘In choosing not to do so, the opportunity was lost, deaths resulted and, 22 years later, it became necessary to establish this panel in order to discover the truth of what happened,’ the authors state.

Nurses failed to protect patients

While the report praises the actions of those night nurses in 1991, it was critical of other nurses at the hospital in that period. It found some failed in their duty to safeguard patients and should have seen the link between the drugs they administered and the shortening of life that followed.

The panel criticised the Nursing and Midwifery Council’s (NMC), other professional bodies and the police for failing to protect patients and relatives. Some put the reputations of the hospital and the professions ahead of patients' interests, the panel said.

NMC fitness to practise director Matthew McClelland acknowledged the regulator had failed families. He said: ‘It’s clear we and others badly let them down and I am very sorry for the role we played in that.’

‘Stark reminder for the NMC’

Mr McClelland said the NMC will now review the Gosport report to see if what action it may need to take.

'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.

‘While the way we regulate nurses and midwives has changed significantly and improved in recent years, this report is a stark reminder that patients and their families must always be at the heart of what we do.’

‘A culture of candour is key – and the parts of the NHS that fall short in this must learn from the best’

Janet Davies, RCN

RCN general secretary Janet Davies said the report makes ‘sober reading’. 

She added: ‘Nursing as a profession must work hard to seek out lessons from Gosport and we expect that approach to be shared by regulators and the health and care system.

‘It highlights how difficult it can be for nursing staff to challenge decisions taken by others. A culture of candour is key to ensuring these events are never repeated and the parts of the NHS that fall short in this must learn from the best.’

Health and social care secretary Jeremy Hunt apologised to the families who lost loved ones for the 'catalogue of failings'.

He told MPs: 'The police, working with the Crown Prosecution Service and clinicians as necessary, will now carefully examine the new material in the report before determining their next steps, and in particular whether criminal charges should now be brought.'

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