What are the lessons from the Gosport report?

What are the lessons from the Gosport report?

James Watts, Consultant in Anaesthesia & Critical Care, looks at the recently published report into the events that occurred at Gosport War Memorial Hospital.

The recently published report into the events that occurred at Gosport War Memorial Hospital [1] where there are alleged to have been approximately 600 unnecessary deaths from excessive opiate usage, come at a particularly sensitive time for the NHS, which not only reaches its 70th birthday this year, but faces one of the biggest financial squeezes of its existence, irrespective of any recently announced cash “birthday present” [2]. However, the issues that arise from the Gosport Report took place over many years, and took decades to surface, spanning the tenures of at least ten Secretaries of State for Health (table 1). This article will review the events that occurred, and will highlight the lessons that are to be learnt for anyone who works in the NHS, from the front line to Whitehall.

Table 1:

Table 1

Gosport War Memorial Hospital

Gosport War Memorial Hospital (GWMH) was part of Portsmouth Hospital NHS Trust (the Trust). The hospital had been under threat on many occasions from NHS reorganisations, but had a lot of local support, particularly from the local MP Norman Lamb, and so stayed open. It seems to have provided a number of outpatient and inpatient services, but the concerns relate to what appears to be an in-patient rehabilitation ward for the elderly. Patients who were admitted were not expected to die imminently, but did require extra support from health and social care services in order to achieve discharge home. A typical patient would be elderly, frail and had either suffered a fracture, or had prolonged immobility, and commonly had either dementia or confusion.

These wards were serviced by consultants, who attended sporadically; but the day-to-day work was delegated to a Clinical Assistant. Dr Barton, who still practised locally as a GP, and who also worked on the PCT, was appointed to this post in May 1988. It was a role that she fulfilled until April 2000. Following her departure in 2000, she continued to work as a GP for many years.

Events

Prior to Dr Barton’s appointment in 1988, approximately 100 death certificates were completed annually at GWMH. From 1992 onwards, death rate steadily increased and doubled by 1998. Following Dr Barton’s departure, it once again fell to 100 per year. This increase in mortality appeared to mirror the hospital’s use of opiate medication on the rehabilitation wards. These concerns were highlighted at the time in a variety of ways, but were not acted upon in a robust manner. The excess deaths were not picked up by the Trust clinical governance system, or the coroner’s service as, in most cases, a routine death certificate could be completed, usually giving the cause of death as “bronchopneumonia”.

In the meantime, the hospital was scrutinised by several outside bodies, including CHI (a forerunner of the CQC). Matters about governance were raised, but in general no intervention was thought to be required.

Issues were raised about the prescription of opiate medication on the wards for many years, as far back as 1982. However, in 1991, the nurses on permanent night shift began to raise concerns about prescribing practice in relation to opiates in general, and syringe drivers in particular. In summary, there was no apparent local guidelines regarding their use, and those that did exist were not applied. There appeared to be no use of alternative or co-analgesics, and medication was not increased in a logical step-wise manner [3)]. Instead patients appeared to be started on potent opiates, particularly diamorphine, at large doses at a very early stage. The use of so-called “anticipatory prescribing”, that is, prescribing a range of escalating opiate dose that could be given at nurses’ discretion, in order to avoid gaps in analgesia, led to patients being on a wide range of doses, on occasion “20-200mg” prn. After a series of meetings, the issue was addressed as routine variability in practice, with the night nurses being reassured that as they were not present during the day that they did not fully appreciate why certain decisions had been made. The nurses were told that the opiates and other medications were required to keep patients “comfortable”. The fact that consultants often changed Dr Barton’s prescriptions when brought to their attention was attributed to legitimate clinical practice variations. In other words, the issues were concluded to be mainly poor communication between different teams.

Some families however began to complain, and eventually went to the police when they did not get satisfactory answers from the Trust or other authorities. Police investigations began in 1998, and took until 2010 to complete. In the end, the Police and Crown Prosecution Service could not prove that criminal acts were taking place, and so no action was taken. The police were however sufficiently concerned to contact the GMC about practices on the ward in 2000. The GMC subsequently opened an investigation and referred Dr Barton to an Interim Orders Committee (IOC). An IOC was a formal panel that would consider whether it was necessary to restrict the doctor’s practise while any investigation was ongoing. While the GMC took the matters at Gosport very seriously, it suspended its investigations on more than one occasion to accommodate the police and various inquests. This had the effect of grossly prolonging the GMC investigation. During this time, Dr Barton continued to work unrestricted as a GP. In the meantime, the Police kept referring new information to the GMC at irregular intervals. In the event, Dr Barton was referred to an IOC on five occasions over the years. The first four panels took no action as she was under “local restrictions”. The final IOC restricted her ability to prescribe and use opiates and other medications in 2008.

The GMC pursued an investigation proper from about 2007, and her case was referred to a Fitness to Practise Panel (FTP) which began sitting in mid-2009. It found that Dr Barton was indeed guilty of serious professional misconduct in her practise at Gosport. However, it took into account her subsequent nine years of unblemished practise as a GP, and accepted her mitigation that she was working in a stressful under-resourced environment and instead of erasing her from the register as expected, placed conditions on her practice for three years. At this time, the FTP panel was formally part of the GMC, but separate to the Investigations Department. In effect, the FTP panels were run independently within the structure of the GMC, and so whilst they had to give weight to the evidence provided by the investigation department and their opinion that erasure was the appropriate sanction, they were not bound by it.

To avoid a theoretical abuse of process, the GMC did not at that time have any legal right to appeal a sanction placed upon a doctor by a panel that it felt was inappropriately lenient. The only path to such an action was for the GMC to request that the Council for Health Regulation Excellence (CHRE) did so. The then Chief Executive of the GMC released a statement to the press in January 2010 announcing the GMC’s intention to do so stating:

We are surprised by the decision to apply conditions in this case. Our view was the doctor’s name should have been erased from the medical register following the Panel’s finding of Serious Professional Misconduct. We will be carefully reviewing the decision before deciding what further action, if any, may be necessary.”

The BMA were outraged by this statement, describing it as “inappropriate and an unwelcome departure from established practice” and “tantamount to an interference in due process”

The CHRE declined to appeal, on the grounds that the punishment handed to Dr Barton was lenient, but within the law separate actions against the ward consultants were closed without action.

The nursing staff were also reported to their regulator, the NMC, by various relatives. The NMC had at this time no formal investigation arm, instead farming out cases to specialist solicitors. The cases were all closed, despite the family’s protests that they must have known that the medication doses prescribed by Dr Barton were inappropriate, but still gave them. It was acknowledged that the solicitors had probably not had the full facts or specialist knowledge at this time. It was legally and logistically difficult for the NMC to re-open these cases, even if they were inclined to do so.

 

Fallout of the case

It is the Barton case that prompted the GMC to petition the Government to change the law, allowing it to appeal disciplinary decisions taken by a panel that in its view were insufficient to ensure public safety and confidence in the profession and the regulator. This was achieved ultimately by splitting off the Tribunal arm of the GMC as the independent Medical Practitioner Tribunal Service (MPTS).

The Gosport report is a clear and coherent document and reported after years of campaigning by the relatives. While most of the patients referred to in the report were not in the best of health, the majority were not expected to die soon, and the report clearly concludes that many were placed on palliative care plans inappropriately, with excessive doses of medication being used. The report stops short of accusing Dr Barton of deliberate ‘Shipmanism’. However, the report’s conclusions were used widely to undermine trust in the medical profession, its regulator and the NHS as a whole by the media and has re-opened a debate on healthcare regulation that has been rumbling for years [4-5].

It is possible that Dr Barton, who is now retired, may face yet another police investigation.

 

Conclusion

Such a scandal preys on the public concerns and political fallout of other such occurrences, such as the Mid Staffordshire Scandal [6], the Shipman murder trial [7] and the Barrow in Furness Obstetric scandal [8], undermining the enormous amount of good work the NHS does. And yet, the lessons to be learnt from each of these cases are depressingly similar. That is, local governance must be more robust. Concerns raised locally must be addressed properly, even if they turn out to be groundless. Managers must foster a “fair blame” environment that encourages raising issues, and be less concerned about “fixing the blame, not the problem”. Hospital managers and politicians need to be more concerned with safety as the main priority rather than reputation. Regional and national mechanisms for ensuring quality need to be more specific, and more reactive. In particular, peaks in mortality should be picked up by outside bodies such as the Coronial service, and addressed more quickly, something which the new (but actually recommended in the Shipman report) role of medical examiner is supposed to facilitate [9]. The department of health should ensure that appropriate regulatory mechanisms are in place, that they function, and that staff will be supported, not punished, for raising concerns and errors. In addition, regulators need to be more stringent in their approach to such allegations, taking swift action where public safety could be at risk.

As the political fallout of these cases continues, what are the actions that individuals can take? Clearly, they must place the patient at the centre of everything, and make everything as safe as possible. Concerns raised locally need to be properly investigated, and any lessons learnt identified and applied. Medical leaders need to establish a “fair blame” culture that will allow any issues to be aired, and addressed. Silo working which fosters secrecy and poor communication needs to be eliminated, and proper supervision and accountability, at a local and managerial level needs to be implemented. Ultimately, all medical practitioners need to challenge what they see as poor processes or instances of patient care. This needs to be done in a supportive environment to allow individuals and organisations to learn. As anaesthetists we have a unique role, seeing as we do in our everyday work how many hospital departments do business, and should be confident in our ability to identify and raise concerns about poor practices.

 

References

  1. Gosport independent Panel Gosport War Memorial Hospital The Report of the Gosport Independent Panel June 2018
  2. Hallows N Call for clarity on NHS funding pledge 28 march 2018 https://www.bma.org.uk/news/2018/march/call-for-clarity-on-nhs-funding-pledge accessed 16t july 2018
  3. The WHO Pain ladder http://www.who.int/cancer/palliative/painladder/en/ accessed 16th July 2018
  4. Paterson S My mother was bullied out of her job for speaking out on Dr Opiate scandal http://www.dailymail.co.uk/news/article-5872585/My-mother-bullied-job-speaking-Dr-Opiate-scandal.html 22nd june 2018 accessed 17th july 2018
  5. Spillett R I did my best’: ‘Dr Opiate’ finally breaks her silence but REFUSES to apologise for early deaths of up to 656 patients and instead blames ‘inadequate resources’ http://www.dailymail.co.uk/news/article-5891141/Gosports-Dr-Opiate-insists-hard-working-dedicated-doctor.html 27th june 2018 accessed 17 july 2018
  6. Report of the Mid Staffordshire NHS Foundation trust Public Inquiry (2013)https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry accessed 17th july 2017
  7. The Shipman inquiry (2002) http://webarchive.nationalarchives.gov.uk/20090808155110/http://www.the-shipman-inquiry.org.uk/reports.asp accessed 17th July 2018
  8. Morcambe bay Investigation report (2015) https://www.gov.uk/government/publications/morecambe-bay-investigation-report accessed 17th july 2018
  9. Twaddell I Medical examiners to review all deaths from 2018 Pulse 10/3/16 http://www.pulsetoday.co.uk/home/finance-and-practice-life-news/medical-examiners-to-review-all-deaths-from-2018/20031346.article accessed 17th july 2017

 

 

Author:

James Watts

BSc MB ChB FRCA FFICM

Consultant in Anaesthesia & Critical Care

East Lancashire NHS Trust

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