Gosport War Memorial Hospital scandal

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The Gosport War Memorial Hospital scandal broke in 2001 and relates to a palliative care approach without appropriate titration to effect for indication, resulting in premature deaths of elderly patients admitted to the hospital between 1992 and 2000. A compliant in 1998 that was not sustained, resulted in due course in a fuller investigation, that was hampered by numerous difficulties. These difficulties included multiple organisations governance failings. The association between these premature deaths and the use of opioids and other palliative care medications, without a clear indication, between the years 1988 and 2001 took 17 years to disentangle. It is interesting that the first potential governance trigger in 1991 that was not in retrospect acted upon appropriately, may have effectively endorsed poor practice. Prior to that point, poor practice may have had little or no impact on mortality as the patients where it happened were mostly terminally ill, and would have died during the hospital stay whatever. It is not impossible that changes in casemix, related to service change and demographics also played a role. The enquiry could not look in detail at before and after staff skill mix changes, or was able to identify casemix peers. This is despite there being multiple cottage hospitals and care homes in the country and no doubt continues to apply. The isolated practitioner issue was dealt with by a resignation, with that practitioner identifing underresourcing as an issue, and the pharmacy, nursing, medical and management resource issues that occurred remain unclear. It is suspected considerable resources were redeployed once the issue was identified. The sequence of events is described in the 2018 Gosport Independent Panel report[1] chaired by The Right Reverend James Jones. Understanding might however not end there, as a fourth police investigation, set up to be independent of the previous partially discredited investigations, was announced in July 2018.

Approximately 500 excess deaths may have occurred. Such excess death rates were not uncommon at the time in the NHS from other aspects of care that impacted predominantly on the elderly such as Clostridium difficile infection. However such causes of excess death were easier to detect from the metrics available at the time. Indeed to this day there is a suspicion that changes in care models, or maintaining current ones, without adequate resourcing, might produce excess death. Accordingly examining statistics for say national excess summer or winter mortality in the elderly has potential political overtones, yet alone the common issue that local politicians will tend to support local services, even if these are challenging to resource.

It is possible to interpret certain events described in the report as the NHS whistle-blower problem, management and systems incompetence facilitated in part by health service reorganisation at the hands of politicians and the tendency of society to scapegoat healthcare workers who were working within under-resourced NHS systems. Other issues include inadequate technology and staff training. Medicines were used, that are used much less commonly 20 years later. The lack of appropriate knowledge to use medicines with optimal safely in some healthcare staff, incomplete documentation, and delegation of treatment decisions still provides challenges for NHS clinical governance to this day. That in fact it was a true systems problem is perhaps suggested by the delay between when the patient risk issue was resolved in 2000 and the publication dates of the Baker Report[2] published in August 2013 (delayed due to police investigations) and that lead to the independent enquiry that was published In June 2018..

It should be noted that deaths in this scandal did not meet the criteria to be considered to be due to the dual effect in palliative care; and we must be careful that this scandal - like the previous one relating to the (misuse of) the Liverpool care pathway does not prevent doctors and health care practitioners from providing best quality care within resources available, for patients where palliation of symptoms during a terminal illness is indicated.