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Gosport Independent Panel

Chapter 3: The experience of patients and families on the wards



The Panel’s analysis in Chapter 2 has exposed the pattern of prescribing and administering opioids at Gosport War Memorial Hospital (‘the hospital’) and the deaths that resulted.


This chapter looks behind the statistics to the experience of patients and their relatives, how the drugs were given and how patients were treated by the nurses, the clinical assistant, the consultants and the pharmacists.


The Panel has had privileged access to the available medical records. While those records rightly cannot be published, this chapter uncovers what they say about what happened on the wards and draws upon a number of case studies and quotations from relatives to convey the reality for patients and their families. The case studies illustrate issues both in the drugs prescribed and administered and the wider standard of nursing care provided to patients at the hospital. Appendix 2 contains fuller versions of the summary case studies featured in this chapter.


This chapter discusses the respective roles and responsibilities of the nurses, the clinical assistant, the consultants and the pharmacists, and in so doing makes a number of points.


This chapter also considers the limited available information about communication at the time with the families of those patients who were treated on the wards. It is important to do so, not least to discount any suggestion that all of the families were consulted about and agreed to the drugs that were administered.