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The findings of the Gosport Independent Panel, which looked at the death of more than 450 patients in a Hampshire hospital, are ‘ truly shocking’, the health and social care secretary has said.
Speaking in Parliament yesterday, Jeremy Hunt gave a statement on the ‘shocking findings’ of the Gosport Independent Panel’s report that revealed 456 patients died at the Gosport War Memorial hospital after inappropriate use of opioids and analgesics.
According to the report, ‘occurrence of opioid usage without appropriate clinical indication’ increased significantly between 1989 and 2000′.
The report stated that ‘there were no instances found in 1987 or 1988, but from 1989 the numbers rose strikingly. This was followed by an equally striking decline over 1999 and 2000, with no instances in 2001.’
Following its investigations, the independent panel, chaired by former bishop of Liverpool the Rt Rev James Jones, also concluded that ‘ there may have been a further 200 such deaths, bringing the overall total to around 650’.
Concerns were raised by whistleblowers working at the hospital in 1991 and by some of the families of the deceased in 1998 but these were ignored, Mr Hunt said.
The police is currently working with clinicians and the Crown Prosecution Service and will ‘carefully examine the new material in the report before determining the next steps and whether criminal charges should be brought’, he added.
Families’ ‘anguish and pain’
Mr Hunt continued: ‘Nothing I say today will lessen the anguish and pain of families who have campaigned for 20 years for justice after the loss of a love one.
‘I can at least, on behalf of the Government and the NHS, apologise for what happened and what they have been through.
‘Had the establishment listened when junior NHS staff spoke out […] and when ordinary families raised concern instead of treating them as troublemakers, many of those deaths would have not happen.
‘I also want to pay tribute to these families for their courage and determination to find the truth.’
Mr Hunt said important changes have taken place since the events. These include:
– The establishment of the Care Quality Commission as an independent inspectorate
– A strong focus on patient safety
– The introduction of the duty of candour
– The implementation of the Learning from Deaths programme
– The establishment of medical examiners across NHS hospitals, which will come into force in April 2019.
Lessons not learned?
In 2013, the Baker report – completed by Professor Richard Baker in 2003 but held back from publication for 10 years on the grounds that it could prejudice any upcoming criminal trial – first looked at the deaths in the hospital.
The publication of the report was withheld after a Government lawyer suggested waiting until the inquest by the General Medical Council was concluded.
Mr Hunt said: ‘Can it be right for our systems to have to wait 10 years before learning critically important lessons that could save the lives of other patients?’.
The Government will bring a ‘more considered response’ to the report in the Autumn, he added.