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September 9, 2018

Medicine Balls, Private Eye Issue 1473, 29June 2018
Filed under: Private Eye — Dr. Phil @ 9:52 am

The Gosport Scandal – another cover-up, another failure of consultant-led care 

At Gosport hospital from 1989-2000, Dr Jane Barton was deviating so widely from the accepted clinical guidelines for prescribing opiate drugs via syringe drivers, that it could be spotted from space. The situation may not have been helped by the use of easily confused syringe drivers, one of which discharged its contents over an hour, the other over 24 hours. Many countries replaced such drivers long before the NHS, which still operates on the CATNAP principle (Cheapest Available Technology Narrowly Avoiding Prosecution). The Gosport inquiry found that hundreds of patients admitted for respite care and rehabilitation, who should never have come anywhere near a diamorphine driver, died shortly after this ‘treatment’ was commenced (often combined with the sedative midazolam). Some of the nurses charged with starting the drivers tried to speak up and were silenced, others accepted that was just how things were done in Gosport. As at Bristol, the institutional blindness to poor practice was known by many people over many years at many levels of the NHS, from the consultants who supervised Dr Barton and reviewed her drug charts, to the managers who failed to act on the concerns of the whistle-blowers and eventually the coroner, police and a full-house of incompetent regulators.

The NHS had plenty other dirty secrets at that time, largely attributable to the stress of trying to provide universal care with insufficient resources. When MD qualified in 1987, junior surgeons would do major operations for the first time unsupervised, with their consultant not even in the hospital. Patients would have no idea about the competence and experience of their surgeon. Doctors of all grades and specialties would work ridiculous hours and make catastrophic errors under pressure, but notes would be lost or altered and they were rarely exposed. Patients were often not told their diagnosis for fear it might upset them, and were usually designated ‘not for resuscitation’ (NFR) by the medical team without any prior discussion with patients or relatives. Staff who questioned such resuscitation policies, such as nursing student Kenneth MacDonald at two Aintree hospitals in 1992 (Eyes passim), found themselves removed or suspended from working on the wards in question.

In such a ‘hard to challenge’ culture, it’s easy to see how Dr Barton’s prescribing prevailed, and nurses could mistakenly believe that patients who weren’t terminally ill but died shortly after commencement of a diamorphine infusion must have been close to death anyway. As the late Dr William Pickering asked ‘Who picks up doctors mistakes?’ (Eyes passim) MD has long agreed with Pickering that the NHS needs a truly independent medical inspectorate – free from loyalty to any NHS institution, professional or political brotherhood – that is properly resourced and  staffed by experienced doctors and nurses who are mandated to swiftly investigate all serious staff, patient and relative concerns, as well as any ‘red flag’ mortality data and unexpected deaths. By having full and swift access to all medical records, inspectors could spot the rudimentary diagnostic and treatment errors that constitute the great bulk of NHS harm, and publish their reports contemporaneously and in full so they can be acted on and learned from,  rather than wait for an inquiry to report 30 years after concerns were raised. This would require significant funding, to be repaid by better outcomes. The Government’s current solution is a lame Healthcare Safety Investigation Branch which only investigates ‘up to’ 30 incidents a year and will keep some of its evidence secret in a ‘safe space’, which hardly inspires confidence.

Opioid drugs such as morphine and diamorphine have revolutionised end of life care, relieving pain and distress, and, when used appropriately, often prolonging a good quality of life rather than shortening it. Individuals can have very variable responses to such drugs, with some requiring much higher doses than others for control of symptoms. Patients need to be carefully monitored and have their spiritual, social and emotional needs tended too as well to give them relief from what Dame Cicely Saunders, founder of the hospice movement, called ‘total pain.’ Towards the end of life,  doses of opioids often need to be increased to relieve pain, but if this shortens life, it is not illegal if the prime motive was to relive suffering (the so-called double effect). A very over-worked Dr Barton was prescribing this palliative care treatment for patients who weren’t terminally ill, often without any discussion or consent from patients or relatives. She may have been doing it ‘just in case’ they developed pain or distress when she wasn’t there, but there were many more appropriate and less risky drugs that should have been used.  It was left to the nurses to decide on the precise dose. ‘Just in case’ became the institutional norm, unthinkingly accepted and often fatal. The fear is that the Gosport scandal may discourage the proper use of opioids in palliative care and any meaningful debate on assisted dying. As with all of medicine, consent, explanation and understanding are key.