Intended for healthcare professionals


Gosport deaths: lethal failures in care will happen again

BMJ 2018; 362 doi: (Published 04 July 2018) Cite this as: BMJ 2018;362:k2931

Linked feature

Gosport: will justice ever be served?

Linked opinion

We must listen when patients or families raise the alarm

  1. Kieran Walshe, professor of health policy and management
  1. Alliance Manchester Business School, University of Manchester, UK
  1. kieran.walshe{at}

The real test of systems of governance is how well they work in practice

Every doctor, nurse, and manager working in the NHS today should read the report about the treatment of elderly patients in the Gosport War Memorial Hospital from 1990 to 2000, which was published last week.1 The document is as important as the reports of previous high profile inquiries into failures of care at mid-Staffordshire Hospital NHS Trust2 or the criminal conduct of Dr Shipman.3

The inquiry report calmly and carefully tells an extraordinary and moving story. It sets out how, from 1990 to 2000, patients admitted to some wards at Gosport were routinely prescribed and administered large doses of opioids (mostly diamorphine) without appropriate clinical indications. Prescriptions for wide dose ranges were written up when patients were admitted, for administration at the discretion of nursing staff, and syringe drivers were commonly used for continuous administration.

This practice was not restricted to patients who were in pain or close to the …

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