Only four days after the Gosport Hospital independent inquiry report was released on the inappropriate administration of opioid drugs which reduced the lifespan of patients, a whistleblower close to the inquiry raised a new alert. Speaking to the Sunday Times in late June 2018, the whistleblower stated those on the Gosport inquiry panel “ignored” evidence of deaths due to the use of specific models of syringe drivers, which posed a known risk to patients. The inquiry report had stated, “The Panel has considered issues concerned with the particular syringe drivers, known by their tradename of Graseby, and is aware of the Hazard Notices which applied. The Panel’s analysis does not rest upon any issue relating to these notices”.
What was the problem with the syringes?
There was a known risk with specific models of syringe drivers whereby those administering drugs using the devices could all too easily make a serious error with the dosage. There are two pumps implicated, the Graseby MS26 and the Graseby MS16A, the former which delivers a set dosage per day, and the latter which is set per 24-hours. The NHS's Purchasing and Supply Agency (PSA) have confirmed the devices look "very similar aside from colour", and therein lies the risk. If a clinician administering and adjusting the dose were to confuse one device for another, the result could be significant under-dosage, or more worryingly, over-dosage. One doctor referenced in The Sunday Times article stated the pumps were “totally confusing” and “really dangerous”.
Dr Jane Barton, who is at the centre of the allegations of over-prescription of opioid medication at Gosport Hospital is believed to have used syringe drivers of the types named above, potentially exacerbating the negative impact on patients of her decision to over-prescribe opiates. In the inquiry report, Dr Barton was linked to the deaths of up to 650 people and creating a dangerous culture in which powerful opiates were routinely and recklessly prescribed.
Potential nationwide impact
The whistleblower has asserted that the Gosport inquiry board by-passed the matter of the Graseby pumps to avoid a nationwide scandal. Not only were these devices used for 30 years, but they are also believed to have been linked to deaths due to over-dose in Wales, South Yorkshire, North Yorkshire, Derbyshire, Devon, Cornwall and the Isles of Scilly, according to the BBC.
In the whistle-blower’s own words, “Anyone who has lost their granny over the past 30 years when opiates were administered by this equipment will be asking themselves, 'Is that what killed Granny?”
Considering the duration and nationwide use of these devices, the scale of the problem may be substantial.
Why were these devices still being used?
The syringe drivers were used widely, especially in palliative care. It is estimated 40,000 drivers were used by the NHS – representing one-quarter of all such devices used worldwide. In 2001, it was assessed 66% of UK and Irish palliative care facilities were using the Graseby MS 26, and 55% had the Graseby MS 16A. There had been numerous incident reports of human error when using these pumps, and as a result, “hazardous product” and safety alerts were issued in 1995. In 1996, Scottish inspectors found evidence of “serious over-infusion and fatality” relating to the use of the Graseby units. And in Australasia around 2005, the devices were completely withdrawn from use in a managed programme, as they did not meet minimum safety standards. But nevertheless, it took the NHS until 2010 to issue a notice recommending the replacement of the Graseby medical devices – and not even this amounted to a formal recall. As a result, deaths continued. It was only 2015 when a deadline for their removal, issued by the National Patient Safety Agency, expired.
Why are high doses of opiates so dangerous?
Diamorphine is essentially medical-grade heroin, and as such, when overused can kill. During the Gosport hospital inquiry, it was discovered that over half of Dr Barton’s patients were recorded ‘as not being pain’ – suggesting they were heavily sedated. And putting patients into a state of heavy sedation for too long carries significant risks. According to The Sunday Times, “One in six deaths in Britain occurred after “continuous deep sedation” in 2007-8, according to researchers at Barts and the London School of Medicine and Dentistry, double the rate in Belgium and Holland”.
The Government’s Response
In response to the allegations made in The Sunday Times, the Department of Health issued the following statement:
“In 2010 urgent guidelines were issued to the NHS on the use of these syringe drivers, advising the NHS to introduce safer equipment. The Gosport Independent Panel has highlighted the use of these devices between 1989 and 2000 in Gosport War Memorial Hospital which will be addressed as part of our response. We remain clear that we would also not hesitate to take further action to improve safety in the light of the report or other evidence as required.”
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