Full text of Bishop James Jones’s statement on hospital opioid scandal in Gosport

Institutionalised practice of the shortening of lives

The documents reveal at Gosport War Memorial Hospital from 1989 to 2000 an institutionalised practice of the shortening of lives through prescribing and administering opioids without medical justification.

The documents show that between February 1991 and January 1992 a number of nurses raised concerns about the prescribing specifically of diamorphine. Their warnings went unheeded, the opportunity to rectify the practice was lost, deaths resulted and 22 years later it became necessary to establish the Panel in order to discover the truth of what happened.

The numbers

The hospital records to which the Panel has had privileged access demonstrate that 456 patients died through prescribing and administering opioids without medical justification.

The Panel concludes that taking into account missing records there were probably at least another 200 patients whose lives were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital.

The pattern of opioid use without appropriate clinical indication followed a clear pattern over time. The Panel found no instances in 1987 or 1988 but the numbers rose markedly followed by an equally striking decline over 1999 and 2000, with no instances in 2001.

Not for the Panel to ascribe criminal of civil liability

It is not for the Panel to ascribe criminal or civil liability. It will be for any future judicial processes to determine whatever culpability and criticism might be forthcoming.

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. Although the consultants were not involved directly in treating patients on the wards, the medical records show that they were not aware of how drugs were prescribed and administered but did not intervene to stop the practice.

Nurses had a responsibility to challenge prescribing where it was not in the interests of the patient. The records show that the nurses did not discharge that responsibility and continued to administer the drugs prescribed.

The documents also demonstrate the suboptimal care and lack of diligence by nursing staff in executing their professional accountability for the care delivered. Patients and relatives were marginalised by the professional staff.

How could the practice continue and not be stopped through police regulatory and inquests processes

Families will ask, how could this practice continue and not be stopped through the various police, regulatory and inquest processes. The Panel’s report shows how those processes of scrutiny unfolded and how the families were failed.

Respective chapters of the report show how the relevant healthcare organisations failed to recognise what was happening at the hospital and failed to act to put it right; how the police investigations were limited in their depth and in the range of possible offences pursued; how the process of the General Medical Council and the Nursing and Midwifery Council were delayed; and how the inquests proceeded.

The documents show how the media coverage played a significant part in encouraging staff who had worked on the wards to take action. And how Sir Peter Viggers, as the local MP, questioned the need for repeated inquiries into had happened at the hospital.

Families in their tenacity and fortitude

Throughout, the relatives have shown remarkable tenacity and fortitude in questioning what happened to their loved ones. The documents explained and published today show that they were right to ask those questions. The families deserve every support in absorbing what is revealed ad whatever future processes now follow.

Completion of the Panel’s terms of reference

The Panel has listened to the families and the documents now highlighted in its report reveal what those documents add to public understanding.

The Panel now calls upon the Secretary of State for Health and Social Care, the Home Secretary, Attorney General and the Chief Constable of Hampshire Police and the relevant investigative authorities to recognise the significance of what is revealed about the circumstances of deaths at the hospital and to act accordingly.

Alongside its report, the panel has published an online archive of documentation. The panel is aware that some documents include personal opinions of individuals and statements about individuals, where those concerned have not had the opportunity to respond to comments or criticism. In reading the disclosed documents it is important to be sensitive to this situation.

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