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Gosport Hospital Inquiry Report Highlights Major Medical Prescribing Failures

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Gosford Hospital Inquiry Report Highlights Major Medical Prescribing Failures

The Gosford War Memorial Hospital is at the centre of a major healthcare scandal concerning the inappropriate administration of opioid medication.  The Report of the Gosport Independent Panel[PM1]  was released on 20th June 2018, following an inquiry chaired by The Right Reverend James Jones KBE, and highlighted serious systemic failures going back to the late 1980’s.

The inquiry report confirms over a 12-year period, as a clinical assistant, Dr Jane Barton was responsible for the practice of prescribing medication on the wards of Gosford Hospital.  As a result, the lives of over 450 patients were shortened between 1988 and 2000, due to the use of opioid painkillers given “without medical justification”.  And there may be another 200 patients who were affected; however, this cannot be fully confirmed due to missing medical records.

Why was the inquiry established?

In 1991, nurses working at the hospital voiced their concerns regarding the improper use of diamorphine (the medical name for heroine).  This led to an internal hospital meeting, where several nurses expressed their view that diamorphine “was being prescribed without due consideration being given”.  Following several subsequent meetings, the hospital failed to address the concerns, and there are suspicions of nurses effectively being “silenced”.  The report highlights several missed opportunities and unheeded warnings, which ultimately allowed the inappropriate prescription of opioids to continue.

Families of those affected by the systemic failures at Gosford Hospital have been campaigning for 20 years for an investigation into the deaths of their loved ones, according to the Independent[1].  On 10th July 2014, the Gosport Independent Panel was established to consult with the families of the deceased and obtain, examine, and analyse documentation relevant to the case.

What were the conclusions of the inquiry?

In addition to the main finding that up to 650 patients may have had their life ended early due to the unjustified use of opioid medication, several other conclusions were presented in the report, namely (as taken from section 12.11 of the report):

  • There was a disregard for human life and a culture of shortening the lives of many patients.
  • There was an institutionalised regime of prescribing and administering “dangerous doses” of a hazardous combination of medication not clinically indicated or justified, with patients and relatives powerless in their relationship with professional staff.
  • When the relatives complained about the safety of patients and the appropriateness

of their care, they were consistently let down by those in authority – both individuals

and institutions.

  • The senior management of the hospital, healthcare organisations, Hampshire Constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) all failed to act in ways that would have better-protected patients and relatives, whose interests were sometimes subordinated to the reputation of the hospital and the professions involved.       

One section of the report deals with the viewpoint that perhaps clinicians administering the opioid drugs inappropriately could be viewed in the context of “end of life care, what a ‘good death’ is, and assisted dying”.   And indeed, many hearing about the case initially may have naturally assumed the negligent actions taken at Gosford Hospital were done in the context of helping patients have an easier death.  The report is extremely clear that this was not the case.  Many patients who died early were not admitted to Gosford Hospital for end of life or palliative care; on the contrary, they were admitted for rehabilitation or respite care.  Therefore, according the report, there is no doubt, the prescribing and administration of drugs was “excessive and inappropriate”.

What was the Health Secretary’s Response to the report?

Speaking in the Houses of Parliament following the release of the report, Jeremy Hunt stated, “Nothing I say today will lessen the anguish and pain of families who have campaigned for 20 years after the loss of a loved one, but I can at least on behalf of the government and NHS apologise for what happened and what they have been through”.  He also confirmed, “the police working with the CPS 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".

Criminal proceedings?

During the investigation the Crown Prosecution Service considered charges of manslaughter and murder in relation to Dr Barton and some of the nurses. However, the CPS concluded there was not a reasonable chance of obtaining a conviction.

Nevertheless, in January 2019 former Assistant Chief Constable Steve Watts, who led the investigation told BBC Panorama he thought the evidence was strong enough to take a case to court. He said, “I think it’s strong enough now, I think it was strong enough then, and I think there was an overriding public interest in doing so”.

The officer also said, "I knew what the response of the families was going to be, I knew what the response of the public was going to be and I recall talking to the prosecutors and saying that this will end up in a public inquiry and eventually I think the matter will go before a court."

Following the initial investigation by Kent and Essex police, police in Hampshire, in January 2019, were reviewing the original evidence to consider if further action was necessary.

Has the Gosford Hospital Scandal affected you?

If you have been affected by the negligent prescribing practices at Gosford Hospital, you may be able to seek compensation.  By speaking to one of our specialist medical negligence solicitors, we can help you confirm if you have a valid claim.  Compensation cannot undo the wrong done, but it can help to bring a sense of closure and justice to families who should have had many more years with their loved one. 

Our personal injury team, led by Malcolm Underhill, has the expertise and knowledge to advise and represent you if you wish to claim compensation for personal injury. To talk about how we might be able to help, please phone us on 0333 123 9099, email us at or fill in our contact form.  Any discussions you have with us will be in the strictest of confidence and handled with the utmost sensitivity


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