KEY FINDINGS

HERE are the key findings of the Gosport Independent Panel...

A pattern of concerning opioid prescribing at Gosport War Memorial Hospital appears to have started in 1989 and ended in 2000. Nurses first raised concerns in 1991 but the warnings were “unheeded”.

Evidence was found of opioid use “without appropriate clinical indication” in 456 patients.

Taking into account missing records, at least another 200 patients were “probably” also affected.

There was a “disregard for human life and a culture of shortening the lives of a large number of patients”.

There was an “institutionalised regime” of prescribing and administering “dangerous doses” of drugs without medical justification.

Over a 12-year period, clinical assistant Dr Jane Barton was responsible for prescribing.

Nurses had the responsibility to challenge prescribing, but continued to administer the drugs.

Consultants were not involved in treating patients, but were aware of how drugs were being prescribed and “did not intervene to stop the practice”.

Patients and relatives were “powerless” in their relationship with professional staff.

When relatives complained about the safety of patients and appropriateness of their care, they were “consistently let down” by individuals and authorities.

The senior management of the hospital, healthcare organisations, Hampshire Police, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and the Nursing and Midwifery Council “all failed to act in ways that would have better protected patients and relatives”.