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Editorials

Gosport deaths: lethal failures in care will happen again

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k2931 (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}manchester.ac.uk

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 end of life; it even included those admitted for rehabilitation and respite care. Most of the patients started on opioids died, often within a few days. The annual death rate in the hospital roughly doubled during this period, from about 100 deaths a year to 200 deaths a year. The panel estimates that between 450 and 650 patients died after being given opioids without clinical justification from 1990 to 2000.

The report shows how it took over a decade for the NHS to respond to concerns about the quality of care at Gosport. Nurses first raised concern with the Portsmouth and South East Hampshire Health Authority in 1991, but they were dismissed after a cursory review. Several patients and relatives expressed concerns over the years to no avail. In 1998 one relative complained to the Hampshire police, who started an investigation, which then widened to include several similar cases.

In 2000, the doctor in charge at Gosport resigned from her duties there and was referred to the General Medical Council, and the Commission for Health Improvement (a precursor to the current Care Quality Commission) started an investigation in 2001—the first of many by various parties.4

The report maps out how the responsible authorities—the police, the GMC, the NHS in Portsmouth, the Department of Health, the Nursing and Midwifery Council, the coroner, and the local MP—responded to the concerns at Gosport from 1998 onwards. Largely, it finds their investigations were inadequate and slow (it took until 2010 for the GMC to conclude its fitness to practise proceedings against the doctor in the case). The inquiry finds that all failed to act to protect patients and relatives properly, and that the interests of patients and relatives were subordinated to the reputation of the hospital, the professions, and the organisations involved.

How to do better

It is shameful that it has taken 20 years for the patients and families to get a proper investigation and report into the failings in care at Gosport hospital. It is shocking that almost none of the doctors, nurses, and NHS managers involved have ever been properly held to account. But what can today’s NHS learn from events which took place up to three decades ago?

Although we now have far stronger systems for clinical governance in the NHS, it would be complacent to argue that failures in care like this could not happen now. Rather, we should presume that problems with divergent, inappropriate, or simply incompetent clinical practice will happen (and indeed, are happening in the NHS today). We should consider that the real test of our professional and organisational systems for clinical governance is how they deal with such problems—how quickly and effectively they are identified, investigated, and remedied.

We should recognise that for all the many and various reforms enacted to improve quality and safety in the NHS in recent years, the culture of medicine and the healthcare professions remains a hugely powerful influence on behaviour. Like many others, this case shows collusive behaviour to protect the professionals involved, deference to professional authority, a reluctance to challenge clinicians’ practice, a desire to cover up problems rather than investigate them, and a tendency to fob off patients and relatives and tell them as little as possible rather than being open and honest.

Perhaps most importantly, this case once again shows the importance of enabling staff, patients, and relatives to speak up when they have concerns, knowing that they will be listened to sympathetically and that they will not face adverse consequences as a result. If senior clinicians and managers in Portsmouth had listened to the group of nurses who came to them with their concerns in 1991 and taken action, a great deal of harm and suffering could have been prevented. It is a tragedy that this opportunity to remedy the problems in Gosport at the outset was missed.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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