Gosport hospital deaths, an update

21 January 2019

Last year following an Inquest into the deaths of hundreds of patients at Gosport War Memorial Hospital 1989 and 2000 it was determined that more than 450 patients died after being given powerful painkillers inappropriately.

It is now reported and updated that the there is strong evidence to bring criminal charges. It is known that Hampshire Constabulary investigated the number of deaths on 3 previous occasions but charges were never brought and that the GP at the centre of the scandal, Dr Jane Barton, was subject to disciplinary proceedings before the General Medical Council (GMC) in 2010, but was not struck off.

There are conflicting reports of what happened. Was it a lone wolf, Dr Barton who was responsible? Were some nursing staff also culpable? Were other doctors also involved? Or was it an overall picture indicative of systemic failings unfortunately so often seen in the NHS when scandals do emerge.

It is noted that Dr Barton indicates that Consultants at the hospital were aware of her prescriptions and did nothing to correct them; that she was working in an inadequately resources part of the health service and that when she received the patients she was under unreasonable and increasing pressure to attend to patients who were not suitable for rehabilitation.

There were suggestions that some of the patients were not ever suitable for morphine drivers and some nurses even felt it was an attempt to keep waiting lists down.

It is evident that many of the death certificates will inevitably be incorrect as morphine overdose or morphine toxicity should be recorded as at least a secondary cause.

It is interesting perhaps that Norman Lamb, Liberal Democrat MP who served as health minister between 2012-2015, advised that department of health officials advised him in 2013 that a public enquiry should not be held after the publication of an official report into the deaths (the 2003 Baker Report). He felt there was a degree of cover up and made the reference to systemic failure. It is however also reported that he was instrumental in the decision to set up the subsequent panel investigation into Gosport.

So we remain a little in limbo.There was clearly negligent administration of multiple morphine drivers and this did contribute to the deaths of more than 450 patients. That was determined during the Inquest. Dr Barton was the doctor providing the prescriptions and therefore will be correctly under greatest suspicion, but the problems seem to go much deeper. If she was singularly culpable the GMC would have struck her off in 2010. If she was singularly culpable she would have been prosecuted earlier. It seems most likely that as Norman Lamb, MP indicated this was a systemic failure of grand proportions, of the type that once in a generation is reported.

We are undoubtedly in an age where reporting and publicity of these scandals is easier. That however should not be an excuse where lessons can be learned.

The NHS has a Duty of Candour. Perhaps this is an incident where a Candour statement needs to be released to right the wrongs and to give proper clarity to those who have been affected.

https://www.bbc.co.uk/news/uk-england-hampshire-46924754

This is being explored in more detail on Panorama: Killed in Hospital, BBC One on Monday 21 January, at 20:30 GMT.

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