Gosport War Memorial Hospital scandal
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 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.