Gosport must be a tipping point for professional hierarchies in healthcare—an essay by 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