Gosport inquiry: GP 'responsible' for practice of lethal opiate prescribing which may have killed up to 650 patients at NHS hospital, inquiry finds

Panel identified 456 patients whose lives were shortened by 'institutionalised' use of unnecessary opiates, and 'probably at least 200' similarly affected where records were not found

Criminal charges could now be brought after an inquiry revealed up to 650 patients died from lethal doses of opiate painkillers given “without medical justification” over 12 years at an NHS hospital, the government has said.

A public inquiry into the care at Gosport War Memorial Hospital in Hampshire found an “institutionalised practice of shortening lives” between 1989 and 2000 – during the tenure of one GP, Dr Jane Barton.

Families, who have battled for 20 years to have their loved ones’ deaths investigated, were “marginalised” by hospital staff when they complained and “failed” by the police and medical regulators who did not act or investigate thoroughly, the inquiry found.

Health secretary Jeremy Hunt told the Commons that it appeared Dr Barton was “principally responsible” for this practice. But senior consultants, nurses and managers at the hospital had been aware of or administered opiates which they should have known could kill.

Mr Hunt said a fuller response would come in the autumn when the government has had longer to consider the report’s findings, but that the Crown Prosecution Service and police would now be reviewing the evidence identified by the inquiry to identify charges.

The Gosport Independent Panel found evidence of opioid use without an appropriate clinical justification in 456 of the patients who died. Taking into account missing records – incomplete or deleted routinely after a set period – it concludes there are “probably at least another 200 patients were similarly affected”.

“The documents seen by the panel show that for a 12-year period, a clinical assistant, Dr Barton, was responsible for the practice of prescribing which prevailed on the wards,” the inquiry chair, former Bishop of Liverpool James Jones, said.

This prescribing was allowed to continue with the awareness of senior consultants and was carried out by nursing staff who “had a responsibility to challenge this prescribing” but did not, the report found.

Established in 2014, the panel reviewed a million pieces of evidence, and spoke to families or sought records of more than 2,000 patients who died at the hospital between 1987 and 2001 – though a quarter of these were missing.

It concludes that between 1989 and 2000, the period of Dr Barton’s tenure where the opioid prescribing of concern occurred:

• There was a disregard for human life and a culture of shortening 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 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

Early in Dr Barton’s tenure, nurses did raise concerns about the prescribing of diamorphine – the medical name for heroin – in 1991 and 1992, Mr Jones said: “Their warnings went unheeded the opportunity to rectify the practice was lost and deaths resulted, and 22 years later it became necessary to establish the panel in order to discover the truth of what happened.”

Another GP, Dr Harold Shipman, who was convicted of the murders of 15 patients in 2000, “cast a long shadow” over the investigation at the hospital and led to a perception of another “lone wolf”, the report said.

But this means the “significant systemic problems” were missed and police investigations of the allegations that Dr Barton was guilty of unlawful killing ignored the wider responsibility of her managers.

These included the hospital’s chief executive and the responsible consultant, Dr Althea Lord, who were approached in a way that “ignored the possibility that they might be subject to investigation”.

At prime minister’s questions today, Norman Lamb, the former health minister in the coalition government, called for a new police investigation into the deaths to be led by an independent police force.

Mr Hunt also said Hampshire Constabulary should “consider carefully” whether another police force should take investigations further.

Mr Hunt added: “The police, working with the CPS 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.”

“I can at least, on behalf of the government and the NHS, apologise for what happened and what they’ve been through.”

Hampshire Constabulary said it would take time to digest the findings, but it was already evident that it included evidence that had not been available at the time of the original police investigations, starting in 2002.

The Nursing and Midwifery Council said it accepted that its response to some of the families had been unacceptable, and would review the reports findings to see if more action was needed.