Health chief urges NHS to learn from Gosport Hospital scandal

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The NHS needs to face up to its failings and ensure a scandal similar to that at the Gosport War Memorial Hospital does not happen again, a leading health chief has said.

“Truly shocking” revelations that more than 450 people had their lives shortened after being prescribed powerful painkillers at the hospital emerged on Wednesday.

A damning report found an additional 200 patients were “probably” similarly administered with opioids between 1989 and 2000, without medical justification.

Speaking on BBC Two’s Newsnight, Stephen Dorrell, chairman of the NHS Confederation, said the health service needed to learn from its mistakes.

He said: “The truth is, the system failed. We need to turn round, face that fact and ask ourselves what we can do to ensure we minimise the risk of it happening again.”

He added: “Because the health service is a massively popular organisation and does massively good work most of the time, there’s a tendency for those who work in the healthcare system to think they did their best.

“Well, on this occasion, their best was nowhere near good enough.”

Members of the families of people who died at Gosport War Memorial Hospital
Members of the families of people who died at Gosport War Memorial Hospital outside Portsmouth Cathedral (Dominic Lipinski/PA)

The inquiry, led by the former bishop of Liverpool, the Rt Rev James Jones, found that whistleblowers and families were ignored as they attempted to raise concerns about the administration of opioids at the hospital.

Nursing staff first raised concerns nearly 30 years ago but their fears were “silenced” by management, it revealed.

Mr Hunt told MPs: “There was a catalogue of failings by the local NHS, Hampshire Constabulary, the GMC (General Medical Council), the NMC (Nursing and Midwifery Council), the coroners and, as steward of the system, the Department of Health.

“Had the establishment listened when junior NHS staff spoke out, had the establishment listened when ordinary families raised concerns instead of treating them as troublemakers, many of those deaths would not have happened.”

Gosport War Memorial Hospital Inquests
Bishop James Jones delivers a statement outside Portsmouth Cathedral after the publication of the Gosport Independent Panel’s report (Dominic Lipinski/PA)

“Good teams have leaders… that set models where they are open and seek comment and criticism, and you look at patient complaints as an opportunity to improve your service, not as an opportunity to get away,” he said.

Suzanne White, head of clinical negligence at Leigh Day and patient safety campaigner, told the programme she believed there was a “real cultural problem” within the health service, and added: “Lessons learnt are always the lines that come out after this, and I think if I was a family today hearing ‘lessons will be learned’, I’m not going to be convinced.”

Following the release of the report, relatives of elderly patients who died at the hospital branded the findings “chilling” and called for criminal prosecutions to be brought.

Mr Hunt told MPs: “The police, working with the CPS (Crown Prosecution Service) 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.”

He said any further investigations should be carried out by organisations not involved in previous probes, suggesting that Hampshire Police should bring in another force.

The panel found that, over a 12-year period as clinical assistant, Dr Jane Barton was “responsible for the practice of prescribing which prevailed on the wards”.

But Mr Hunt questioned whether there had been an “institutional desire” to blame the events on a “rogue doctor” to protect reputations rather than address systemic failings.

The panel said the case of GP Harold Shipman, who was jailed in 2000 for murdering 15 patients, had “cast a long shadow” over events at the hospital.

The perception that Dr Barton might be a “lone wolf” operating alone “rapidly took root”, the report said.

Police did not pursue a “wider investigation” into what was going on at the hospital and instead focused on the actions of Dr Barton.

Bridget Reeves, the granddaughter of 88-year-old Elsie Devine, said in a statement on behalf of the families: “This has been sinister, calculated and those implicated must now face the rigour of the criminal justice system.

“Accountability must take precedence here.

“These horrifying, shameful, unforgivable actions need to be disclosed in a criminal court for a jury to decide and only then can we put our loved ones to rest.”

The Gosport Independent Panel found that hospital management, Hampshire Police, the CPS, GMC and NMC “all failed to act in ways that would have better protected patients and relatives”.

Its report also highlighted failings by healthcare organisations, local politicians and the coronial system.

It revealed “there was a disregard for human life and a culture of shortening lives of a large number of patients” at the Hampshire hospital.

The report added: “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.”

Concerns were first raised by nurses in 1991 but these warnings went “unheeded”.

When relatives later complained, from 1998, they were “consistently let down by those in authority, both individuals and institutions”.

The report concludes: “The panel found evidence of opioid use without appropriate clinical indication in 456 patients.

“The panel concludes that, taking into account missing records, there were probably at least another 200 patients similarly affected but whose clinical notes were not found.

“The panel’s analysis therefore demonstrates that the lives of over 450 people were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital, and that probably at least another 200 patients were similarly affected.”

In 2010, the GMC ruled that Dr Barton, who has since retired, was guilty of multiple instances of professional misconduct relating to 12 patients who died at the hospital.

Dr Jane Barton, who was found guilty of serious professional misconduct by a Fitness to Practise Panel at the General Medical Council (GMC) in 2010 (Chris Ison/PA)
Dr Jane Barton was found guilty of serious professional misconduct by a GMC Fitness to Practise Panel in 2010 (Chris Ison/PA)

However the Rt Rev Jones said events at the Gosport War Memorial Hospital were distinct, because they showed a “failure of the institution”.

Nurses on the ward were not responsible for the practice but did administer the drugs, including via syringe drivers, and failed to challenge prescribing, the panel said.

Consultants, though not directly involved in treating patients on the ward, “were aware” of how drugs were administered but “did not intervene to stop the practice”.

Mr Hunt also questioned why consultants or nurses did not act to stop those involved.

He added: “Was there an institutional desire to blame the issues on one rogue doctor rather than examine systemic failings that prevented issues being picked up and dealt with quickly driven, as this report suggests it may have been, by a desire to protect organisational reputations?”

Hampshire Police said it would be taking “time to properly digest the significance of what has been revealed”.

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