Intended for healthcare professionals


Gosport must be a tipping point for professional hierarchies in healthcare—an essay by Philip Darbyshire and David Thompson

BMJ 2018; 363 doi: (Published 25 October 2018) Cite this as: BMJ 2018;363:k4270
  1. Philip Darbyshire, director1,
  2. David Thompson, professor of nursing2
  1. 1Philip Darbyshire Consulting, Adelaide, Australia
  2. 2School of Nursing and Midwifery, Queen’s University Belfast, Belfast, UK
  1. Correspondence to: P Darbyshire pdcltd{at}

All healthcare staff must be empowered to question the decisions of colleagues at every level and to have their concerns heard without reprisal, write Philip Darbyshire and David Thompson

The independent report into the deaths of about 600 patients at Gosport War Memorial Hospital in the 1990s is a wake-up call to every health professional.1 The families affected deserve more than for this report to be shelved and forgotten.

Many healthcare professionals imagined we would never read anything more appalling than the Francis report on the major failings at Mid Staffordshire NHS Trust or the Morecambe Bay report on avoidable deaths at the maternity department of Furness General Hospital.

We were wrong. The Gosport report concluded that “older patients,” some of whom had been admitted for rehabilitation or respite care, had their lives “shortened,” largely by the administration of “continuous opioid use” that was “not clinically indicated or justified.”1

Although prescribed by a doctor, the drug combinations (including diamorphine, midazolam, and hyoscine) were usually administered by nurses, who often determined exact doses and any additional doses prescribed as required (prn).

Gosport’s litany of communications failure, prevarication, deliberate delay, cover-up, obfuscation, professional self interest, and buck passing will shock even the jaded practitioner who has read it all before. The focus of this essay is dysfunctional interprofessional communication and the notorious “doctor-nurse game.”2

The “doctor-nurse game”

The report suggests that doctors and nurses have made little progress in improving working relationships since the US psychiatrist Leonard I Stein described the hierarchical “doctor-nurse game” some 50 years ago.2 Stein described a dance of deference, a “transactional neurosis,” whereby medical, nursing, and societal hierarchies shaped how nurses can influence care, treatment, and clinical decisions only by subtle suggestion and by ensuring that their ideas and proposals appear to be the doctor’s autonomous …

View Full Text

Log in

Log in through your institution


* For online subscription