The GP who “shortened” 450 lives
Imagine a “dark corner” of the healthcare system, where older patients are “put to sleep” with powerful drugs, said Judith Woods in The Daily Telegraph. They may be suffering from a bone fracture, and in need of nothing more than physio and paracetamol; they may be sitting up in bed, chatting to nurses and loved ones, and looking forward to going home. But none of this will save them, because “someone somewhere has unilaterally” deemed their lives not worth saving. It would sound like the plot of a horror film, but as we know now, that is what went on for 12 years at Gosport War Memorial Hospital in Hampshire from the late 1980s. According to the Rt Rev James Jones’s independent inquiry, published last week, at least 456 elderly people died after being administered opiate painkillers with no medical justification. “There was a disregard for human life and a culture of shortening lives”, is the report’s chilling conclusion. Among those to have had their lives “shortened” was Robert Wilson, 74. He’d broken a shoulder and was sent to Gosport for rehabilitation. Instead, he was prescribed high doses of morphine and diamorphine, and died four days later. “They’re killing me”, were his last words to his son.
Presiding over all this was Jane Barton, an Oxford-educated GP, described as formidable and brusque, who had chosen to extend her working hours by taking on a role as a ward clinician. It seems nurses soon learnt to interpret her instructions: “make patient comfortable” was a euphemism for giving high doses of painkillers to patients, though many were not even in pain. It was followed by “I am happy for nursing staff to confirm death”. The Daedalus ward was a rehabilitation ward, yet its fatality rate was so high, staff called it the “dead loss” ward.
As early as 1991, two night nurses became convinced that patients were dying unnecessarily, said Sue Reid in the Daily Mail. They courageously reported their concerns, only to be accused of “making waves” by colleagues and managers, who closed ranks against them. Seven years later, Gillian Mackenzie was so concerned by the sudden death of her frail but mobile 91-year-old mother, Gladys, who’d been sent to Barton’s ward to recuperate from a hip operation, she went to the police. That triggered the first of three investigations, none of which led to prosecutions. Other relatives who raised alerts (more than 60 did in total) were dismissed as troublemakers, while the local health authority did nothing. In 2009, an inquest found that painkillers had contributed to the deaths of five of Barton’s patients, and in the wake of the Harold Shipman murders, she was called before the General Medical Council (GMC) in 2010. It found her guilty of misconduct, yet did not strike her off; she retired two months later.
The families did not give up, however: they staged further protests until, in 2014, the coalition launched the Jones Inquiry. Jones – the former bishop of Liverpool who chaired the Hillsborough Inquiry – deserves thanks for his public service, said The Guardian. His report is comprehensive and devastating. Patients and families were not just failed by a single doctor, but by the consultants, who must have been aware of Barton’s prescribing policies, yet did not intervene; the NHS bosses, who ignored the mounting evidence of a serious problem; the police, who failed to gather crucial evidence; and the GMC, which took ten years to discipline Barton. Time and again, said The Observer, failures in care are compounded by the NHS’S “complete unwillingness” to listen to complaints and respond to them. It is outrageous that the families had to wait 20 years for this verdict. With the NHS so stretched, it’s too much to hope that we won’t see more unnecessary deaths, but with luck, new measures to protect whistle-blowers will prevent future cover-ups.
By the time NHS scandals come to light, it is often the case that years have passed. That makes it easier for officials to claim that “it would never happen now”. But I wouldn’t be so sure, said Raj Mattu in The Daily Telegraph. As a whistle-blower myself, I know that people who speak out still face severe repercussions: too often they’re branded troublemakers, discredited and unfairly dismissed, leading to employment disputes in which their original complaint is forgotten. Until staff are afforded proper independent protection, and the NHS starts to welcome criticism, as a chance to learn from its mistakes, these scandals will continue. Indeed, one is already unfolding, said The Sunday Times. Our investigation reveals that for years, staff at hospitals around the country (including Gosport) delivered opiate drugs to patients via cheap syringe drivers that were known to be faulty, and vulnerable to human error and tampering. There were warnings that these were causing “serious over-infusion and fatality” as long ago as 1996, yet they were only withdrawn in 2015. The Gosport scandal may turn out to be a “cover-up within a cover-up”.
“Failures were compounded by a ‘complete unwillingness’ to listen to complaints and respond to them”