Gosport - what the hell happened?

[allthatmalarkey]

I'm reading about the 456 'unnecessary' deaths at Gosport War Memorial Hospital in the 90s and I feel like there's something missing in the story. Why would the doctors do what appears to have happened? I appreciate this is likely to come to be explained at some point, but can anyone shed any light right now?

Huge sympathies to the families of course. Horrendous they've had to fight to be listened to.

I wondered the same tbh

I don't get it either...working in healthcare now I have to fight tooth and nail to get people the pain management they need (quite rightly as well, I'd hate to administer something that could end someone's life in this way!) so I don't get how a Dr prescribed such powerful opiates to people who weren't end of life or had major long term conditions requiring serious pain medication, and no one questioned it.

Shocking.

I wonder if a Harold Shipman figure is going to be named. It's such a tragic case.

Apparently nursing staff did whistle blow but were ignored 😡

Why would you give someone who's suffered a stroke or a broken arm diamorphine on a driver?? I've looked after people who have had strokes and they've had nothing like that in hospital but I guess pre-Shipman it was different?

I do think everyone involved should be held accountable. If that occurred now, every HCP on the paper trail would rightly be hauled over the coals by numerous authorities - from CQC, the GMC to the Police. So why because it happened years ago are they allowed to just carry on practising or with their lives? Crazy.

And YY to the nurses who tried to whistleblow and were silenced. Disgusting.

The whole unit sounds rotten to the core when you read the full report - with the very honourable exception of the night staff and heath care assistants who made valiant attempts to whistleblow and were ignored.

Massive doses of opiates were prescribed and left to the discretion of nurses to administer - who were in some cases doubling amounts every day. People were dying within 30 minutes of being given diamorphine - I've been in palliative care for 15 years and this has happened to me once in my whole career just for perspective. The average lifespan on a syringe driver was 2 days - in my hospice, people take as long to die as they need.

The doses written in the report are mind blowing and so out of keeping with practice at the time. I qualified in 1999 and you could barely get diamorphine written up for anyone who was actually dying, everyone was so terrifed of it.

The report is very clear that the consultants weren't supervising or noticing the dramatic increase in deaths, the nursing staff and unit manager weren't completing proper care plans and documentation and had a 'we know best' attitude, pharmacy seem to be absent and so on.

There seems to have been a complete absence of knowledge of palliative care, how to look after older people and how to care for people with dementia.

I haven't read all the details yet....feel quite cross as it's difficult to get pain relief at times for the line of work I'm in.

An investigation going on for years into one of the doctors 😡. Years!!! If it was a nurse, they would've been struck off

I wondered too. It was a real fight to get my
Mum the end of life pain relief she needed and Shipman was mentioned more than once. Made me want to fucking scream because my mum was writhing and crying out in agony.

Yet this happens unchecked for years? Something stinks, it can’t just have been one doctor.

There were apparently two police investigations already!

If it was someone acting on their own, it would make more sense, but senior doctors were aware of what was being administered. They may have been lied to about the condition of the patients, I suppose.
I had a friend who worked in oncology in the 90s and fell out with her seniors because she felt people were not being told the truth about their condition (eg not being told it was terminal and they had little time to live) and everything was very high handed. Families weren't being made aware of the reality of how opioids shorten life (but having seen a relative flinching in pain despite being in a coma on a driver, that doesn't trouble me in the right circumstances). However, I can't believe it was so bad that in one hospital people were being euthanased in massive numbers. Is that possible?

Sorry, lots of stuff has come in since I started writing that and don't see. Thanks @AnnaMagnani , that's very helpful.

And fuuuuuck!

I do remember said friend talking about death rates as something that only started to be looked at around 2000. And it was initially seen as an irritating distraction from work!

I've just looked up the Shipman dates. His crimes were between 1975 and 1998.

Perhaps the simple answer is that doctors thought putting down patients more acceptable then, and once doctors start killing patients it becomes easier and easier to do it again on increasingly flimsy grounds.

The BBC said that the doctor was recording the cause of death as pneumonia when patients were dying after orthopaedic surgery, which meant that the coroner wasn’t informed as should have happened, and also that patients with fractures were treated palliatively.

The Department of Health refused to release a report on it in 2003, the GMC didn't strike the junior doctor off in 2009, (although allegedly consultants, nurses, pharmacists all colluded). Why is it the lesson that covering things up is always the worst thing to do (not just morally but practically) doesn't seem to sink in with some institutions.

Well, we have to remember that we're dealing with the State. By which I mean, State-affiliated institutions. Therefore, cover-up will be innate. It's just the way they do things. 'The State' has a particular character, it is basically like a rotten firm or office, only every avenue you seek will be rigged, be it the local NHS CCG, the local Council, the NHS primary care trust, the police (sister organisation to the Council) and right up to the GMC (in this case) and also the NMC is manifestly corrupt.

These State-affiliated bodies can use the State machinery to orchestrate any cover-up of any wrongdoing. I should point out that they don't quite see it as 'corrupt' - rather it's ensuring the system works really well and is watertight. You make a complaint, it goes nowhere, it is not upheld - therefore nothing to see here! Anyone decent who raises concerns gets smeared and shafted.

As for why, well, it's simples. Dead bodies save the State a fortune. Save the local NHS CCG a fortune in medication, the Council a fortune in adult social care, you are working through a backlog.

Some day someone will look at the low hydration levels in Surrey care homes and figure out what is going on. Is it, say, a policy? In the meantime, it will take 30 years for the truth about this to emerge, but I'll point out that corporate murder via dehydration is a lot safer for a local authority/NHS CCG than using opiates, which of course leaves traces.

Here's a link to the 2003 report:

A Review of Deaths of Patients at Gosport War Memorial Hospital Final version : October 2003
Richard Baker Clinical Governance Research and Development Unit Department of Health Sciences University of Leic
assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226263/review_gosport_war_memorial_hospital.pdf

Here's a link to the new report published yesterday:

Gosport War Memorial Hospital: The Report of the GosportIndependent Panel Ordered by the House of Commons to be printed on 20 June 2018
www.gosportpanel.independent.gov.uk/media/documents/070618_CCS207_CCS03183220761_Gosport_Inquiry_Whole_Document.pdf

Great. Pain is already chronically under treated in healthcare, so cases like this will only make things worse. I regularly have to care for people who are in agony, yet I have to beg the GPs to prescribe piddling amounts of oramorph (which doesn’t work anyway).

Newspaper the reason why people become dehydrated in care homes is because there aren’t enough staff to constantly give people drinks. They often can’t do it themselves due to dementia or physical disabilities. You can’t force people to drink either. Of course dehydration isn’t a ‘policy’.

This is shocking. My nurse friend was telling me that she has to fight to get things prescribed during palliative care in case the patients 'get addicted' I do not understand how this has occurred .

It’s occurred due to Shipman. Therapeutic doses are no longer prescribed in case they cause the patient to die, as a side effect of these drugs is that they can surpress breathing. No doctor wants to be responsible for someone’s death even if they are terminally ill. I’ve had relatives that have objected to opiate based analgesia in terminal illness, for what reason, god only knows.

People have a really weird and distorted view about pain relief in this country. It’s as if suffering is somehow desirable. Cases like this will only lead to more suffering as prescribers dig their heels in.