Faulty opiate injection pumps used in Gosport scandal to be reviewed amid fears over deaths across NHS, Hunt says

Officials will 'urgently look into this matter to ensure that no unsafe devices of this kind are being used'

Jeremy Hunt has pledged a review of devices used to administer powerful drugs and painkillers after a whistleblower implicated them in thousands of deaths across the health service.

The review comes in the wake of revelations that at least 456 people were killed by medically unnecessary opiates over a 12-year-period at Gosport War Memorial Hospital in Hampshire.

Many of the patients who died had excessive opiates prescribed, but their deaths could have been hastened by automatic syringes which were used across the NHS to deliver drugs until 2015.

That occurred despite warnings over the risk of fatalities from user error going back to the 1990s, with doctors raising the alarm that confusing two models of the infusion pumps could lead to a day’s dose of drugs being delivered in one hour.

Speaking on The Andrew Marr Show on Sunday, Mr Hunt said officials would “look at whether the NHS did react quickly enough when it first found out about the safety consequences of these syringes".

A whistleblower on the government inquiry into hundreds of deaths at the Gosport War Memorial Hospital spoke to The Sunday Times after the panel’s report was limited in its findings on the devices.

“Anyone who has lost their granny over the past 30 years when opiates were administered by this equipment will be asking themselves, ‘Is that what killed Granny?’,” they told the paper.

A 2008 paper by the NHS’s now-defunct Purchasing and Supply Agency (PSA) said the devices were an “essential component of palliative care”.

Around 40,000 of the devices – a quarter of the worldwide total – were in the UK, the majority in primary care.

Doctors had raised concerns over the Graseby MS26 and Graseby MS16A syringe drivers after cases emerged of the devices causing dangerous over-infusion of drugs because of confusion caused by differences in their function.

The PSA said the devices, which appeared “very similar aside from colour”, delivered drugs at different rates.

“Confusing MS16A (which delivers in mm per hour) with MS26 (which delivers in mm per 24 hours) can result in an infusion rate 24 times higher than required, and numerous adverse incidents of their type have been reported,” the PSA said.

The devices had been designed before the introduction of International Electrotechnical Commission (IEC) standards intended to ensure the safety of such infusion pumps, the PSA added.

Hazard notices were issued by the Medicines and Healthcare products Regulatory Agency (MHRA) and its predecessor, the Medical Devices Agency (MDA), to ensure NHS staff knew the difference between the models.

Meanwhile “many” palliative care services only used one type to avoid confusion.

The report added: “Currently, there are safer alternatives to the MS26/MS16A drivers on the UK market; two of which comply with (the IEC standard).”

Of four brands of syringe drivers compared by the PSA, those made by Graseby were the cheapest to run.

A hazard notice issued by the Scottish NHS in 1994 warned of the risk of death from incorrect rate setting due to confusion between the two models.

“Incidents continue to be reported in which confusion between Graseby Medical MS16A and MS26 ambulatory syringe drivers has led to incorrect infusion rates being set, resulting in serious over-infusion and fatality,” the notice said.

Meanwhile the National Archives holds records of an MDA safety notice being issued over the pumps in 1995.

In the late 2000s, Australia and New Zealand had programmes to remove the MS devices from use, although there was no similar central initiative in the UK.

In 2011, the National Patient Safety Agency recommended that all Graseby syringe drivers should be withdrawn by 2015, however it stopped short of a mandatory recall.

A damning report released this week said more than 450 people had their lives shortened after being prescribed powerful painkillers at Gosport War Memorial Hospital.

An additional 200 patients were “probably” similarly given opioids between 1989 and 2000 without medical justification.

The report said: “The panel has considered issues concerned with the particular syringe drivers, known by their tradename of Graseby, and is aware of the hazard notices which applied. The panel’s analysis does not rest upon any issue relating to these notices.”

A Department of Health and Social Care spokesman said: “Following a safety alert issued in 2010, these specific syringe drivers should have been withdrawn completely by the NHS by 2015.

“However, the Health Secretary has asked officials to urgently look into this matter, to ensure that no unsafe devices of this kind are being used.”

Additional reporting by PA