An “institutionalised regime” of prescribing and administering opioids without medical justification shortened the lives of at least 450 people, an independent panel into care at a Hampshire hospital has found.
The panel revealed “there was a disregard for human life and a culture of shortening lives of a large number of patients” at Gosport War Memorial Hospital.
More than 456 patients died there after the use of strong opiate drugs between 1989 to 2000, but the panel found “no medical justification” for such painkillers being used.
Led by the former bishop of Liverpool, James Jones, the panel reviewed 833 death certificates signed by one doctor at the facility, Jane Barton, and examined more than one million documents.
Both Theresa May and Jeremy Hunt apologised to the families while addressing MPs in the House of Commons on Wednesday afternoon.
The findings were first revealed to relatives at Portsmouth Cathedral on Wednesday.
Outside the cathedral, Jones told gathered reporters: “The relatives have shown remarkable tenacity and fortitude in questioning what happened to their loved ones.
“The documents explained and published today show they were right to ask those questions. ”
He later told a press conference in Portsmouth that the families were “enormously appreciative of what the report has said”.
He said: “Their reaction was, understandably, emotional and I think the way they reacted showed them just how much they had carried inside themselves over 20 years or so.”
He said there had been “lots of tears” and “grieving” when families were presented with the findings of the report on Wednesday morning.
During Prime Minister’s Questions, May told MPs the events at the hospital were as “deeply troubling” and she apologised to families over the time it took to get answers from the NHS.
Hunt later added his own apology to relatives for the “truly shocking” deaths of their loved ones. He said the police and the Crown Prosecution Service would have to consider their next steps and “whether criminal charges should now be brought”.
The inquiry found that hospital management, healthcare organisations, Hampshire Police, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and the Nursing and Midwifery Council “all failed to act in ways that would have better protected patients and relatives”, the panel said.
The report said: “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 or raised concerns, they were “consistently let down by those in authority – both individuals and institutions”.
Bridget Reeves - whose grandmother Elsie Divine, 88, died at the hospital in 1999 - acted as spokeswoman for the families and spoke to reporters in Portsmouth on Wednesday afternoon.
She said their vulnerable relatives had been “stripped of their final words to their loved ones” and “silenced by overdoses”.
She said: “None of us would have allowed our relatives to be admitted into Gosport War Memorial Hospital had we known there was an ongoing police investigation in 1998. The people of Gosport had the right to know and there would have been outrage had they known the concerns of the whistleblower some 10 years before.”
She said there had been 12 investigations into what had happened to their families, but an “inequality of justice” had hampered justice.
She said the failure of all previous investigations and reports, was “not only shameful but also scandalous and immoral”.
The panel found that, over a 12-year period as clinical assistant, Dr Barton was “responsible for the practice of prescribing which prevailed on the wards”.
In 2010, the GMC ruled that Dr Barton, who has since retired, was guilty of multiple instances of professional misconduct relating to 12 patients who died at the hospital.
Nurses on the ward were not responsible for the practice but did administer the drugs, including via syringe drivers, and failed to challenge prescribing, the panel said.
Consultants, though not directly involved in treating patients on the ward, “were aware” of how drugs were administered but “did not intervene to stop the practice”.
The inquiry did not ascribe criminal or civil liability for the deaths, however it said the government and relevant public authorities “will want to consider the action that now needs to be taken” to further investigate what happened at the hospital.
Campaigners have called for tougher action following the publication of the report.