Gosport War Memorial Hospital Deaths – What has happened, and why?

In 2018 a report was published which heavily criticised the care received by patients on two elderly people’s wards at Gosport War Memorial hospital. The report showed powerful opiate painkillers called diamorphine were being prescribed for patients who did not need them, and as a result patients between 1988 and 2000 may have died earlier than they should have.

Nurses at the hospital had tried to report their concerns in the late eighties, but were warned not to take the matter any further.

Since the publication of the report, a criminal investigation has been launched into the deaths at the hospital.

Who has been blamed for the Gosport hospital deaths?

The doctor at the centre of the scandal is Dr Jane Barton, a clinical advisor on the wards in question. Dr Barton was responsible for prescribing most of the diamorphine, and for authorising the use of “syringe drivers” (machines which pump a constant supply of the drug into patients).

In this hospital, the drip was inserted into a patient’s back so they could not disconnect themselves, and the dosage was not tailored to individual needs. Dr Barton would often write “please make comfortable” and “I am happy for nursing staff to confirm death” on patient notes, and this was done even when they had been admitted for rehabilitation, not end of life care.

Dr Barton was supervised by several consultants who should have been aware of how she dealt with patients, but they have not been the focus of the adverse media coverage around the scandal.

Why did no one listen to the nurses?

Often in large organisations there becomes a pressure to not “rock the boat” or cause a situation which makes more work for people, or means it is likely the organisation will be viewed negatively by those outside it. There is often the fear that “blowing the whistle” on wrongdoing will lead to the loss of your job, or worse.

In this case, nurses were warned that having given the hospital an opportunity to correct the over-prescriptions was enough. This is another example of whistleblowers who encountered internal barriers that thwarted their efforts.

Why did it take so long for these errors to be investigated?

Families of the patients treated by the hospital had been attempting to have their relatives’ treatment investigated since 1998. Several health investigations took place, and Hampshire Police became involved. None of the investigations found any evidence of wrongdoing, and following complaints about the quality of their investigation, Hampshire Police would later confirm that it had not been carried out correctly.

It was not until 2003 when Sir Liam Donaldson, then Chief Medical Officer, requested a review that the level of failings within the wards became known.

Sadly, that report would not be made publicly available to families for another ten years, by which time the inquiry which produced the report published in 2018 was already underway.

What will happen to Dr Barton?

In 2009, Dr Barton was called before the General Medical Council, because four inquests had found that the drugs she prescribed had hastened the deaths of patients. Although she was criticised, she was not struck off, and could have continued to practice. However, she chose to retire and be erased from the medical register, and has not practised since.

Many of the families who lost relatives to her care are still unhappy with this decision, and the fact that Dr Barton has not been criminally prosecuted.

How many people died because of this negligence?

The inquiry believes that of the 833 Gosport hospital deaths Dr Barton certified between 1988 and 2000, 456 died and possibly 200 more had their lives shortened because of the prescription practices used by the hospital.

The dangers of unsupervised death certification had previously been considered by the Shipman enquiry, and had the recommendations of the Shipman enquiry already been in place, this is a scenario that would not be permitted today.

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