Chapter 12: Summary and conclusions
Introduction and key conclusions
In waiting patiently for the Panel’s Report, the families of those who died at Gosport War Memorial Hospital (‘the hospital’) will be asking: “Have you listened and heard our concerns, and has the validity of those concerns been demonstrated?”
It is over 27 years since nurses at the hospital first voiced their concerns. It is at least 20 years since the families sought answers through proper investigation. In that time, the families have pleaded that “the truth must now come out”. They have witnessed from the outside many investigative processes. Some they have come to regard as “farce” or “cover-up”. Sometimes they have discovered that experts who had found reason for concern had been ignored or disparaged. Sometimes long-awaited reports were not published.
The Panel has now completed its work. It has listened and heard the families’ concerns and interrogated documents and personal medical records – including over one million pages of documents – which in their entirety had not previously been independently reviewed.
Having looked at documents covering the whole period since 1987, the Panel can say: “Yes, we have listened and yes, you, the families, were right. Your concerns are shown to be valid.” Indeed, as this Report shows, the practice of anticipatory prescribing and administering opioids in high doses affected many patients and families – not only those who have led the way in pressing for the truth, but also very many other families.
Opioids are powerful drugs that bring significant benefits when used appropriately, but they carry commensurate risks. The Panel’s analysis demonstrates that the lives of very many people were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital.
For the initial group of 163 patients drawn to the attention of the Panel (the Initial Group), clinical records or key parts of them were not available in 58 cases. For the remaining 105 patients, the Panel found that in 71 cases there was evidence that opioids were used without appropriate clinical indication.
The starkness of this finding raised immediate concern that other patients, of whom we were not initially aware, might also have been affected. The Panel therefore sought all the clinical records for the 2,024 patients whom it was aware had died in the hospital between 1987 and 2001. The Panel found hospital records for 1,564 of these patients, and examined them for evidence of opioid use without appropriate clinical indication. In 1,043 of these patients (the Wider Group), there was sufficient information available for the Panel.
In 385 of the Wider Group of patients, the Panel found evidence of opioid use without appropriate clinical indication.
In summary, the Panel found evidence of opioid use without appropriate clinical indication in 456 patients. The Panel concludes that, taking into account the 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 short, during the period between 1989 and 2000 at Gosport War Memorial Hospital, which appears to cover the start and end of the pattern of opioid prescribing of concern, the disclosed documents reveal that:
- There was a disregard for human life and a culture of shortening the lives of a large number of 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 some subordinated to the reputation of the hospital and the professions involved.
Relatives of patients at the hospital could have hoped that those responsible for healthcare would have identified what had happened, or that the various investigations conducted since they sounded the alarm would have done so. This Report has described how many experts were called upon to offer their opinion. However, none of them had access to the full range of medical records.
The families, and indeed the nation as a whole, are entitled to ask how these events could have happened; how the hospital dismissed the nurses’ concerns and subsequently took no action; how the healthcare organisations failed to intervene; how the professional regulators allowed matters to continue; how the police failed to get to the bottom of what had happened; and whether what happened is to be explained as a conspiracy or in some other way.
From the documents it has examined, the Panel has been able to answer these questions as set out in this chapter. The Panel’s Terms of Reference did not extend to any hospital other than Gosport War Memorial Hospital, then or now. So the Panel cannot speculate on whether anything similar to what happened at Gosport War Memorial Hospital also happened elsewhere.
It is not the Panel’s role to ascribe criminal or civil liability. The Secretary of State for Health and Social Care and the relevant public authorities will want to consider the action that now needs to be taken to further investigate what happened at the hospital. The Secretary of State will want to ensure that families who believe they were affected by events at the hospital have the support they deserve going forward, and also to consider wider lessons.