Learning from failures of care at Gosport

Catherine Picton, Professional Secretary, RPS Hospital Expert Advisory Group

At least 450 patients are thought to have died after the administration of inappropriately high doses of opioids between 1988 and 2000 at Gosport War Memorial Hospital. In June 2018 the report of the Gosport Independent Panel into failures of care was published.

Like many reading the report I was shocked. Most sobering was that this practice remained unchallenged for a prolonged period of time, despite initial concerns being raised by relatives of patients and nursing staff, and prescribing being outside accepted good practice.

Could it happen again?

Hospital pharmacy practice has moved on in the decades since 2000, and ever-increasing use of technology and data driven care mean that trends in medicines use and anomalies in prescribing can be identified more efficiently. Pharmacists are more integrated into multidisciplinary ward teams, making them better able to challenge when they think patient safety is compromised, and there is increased scrutiny of both medicines safety practices and the safe use of controlled drugs, largely due to measures introduced post-Shipman.

Today, the practices that survived in Gosport War Memorial Hospital would be unlikely to go undetected for so long. However, we still need to ensure that systems and ways of working are clearly focused on patient safety and that this remains a high priority for pharmacists and their teams.

Moving forward

Patients and carers should expect pharmacy teams to provide information about medicines and to be their medicines safety advocates. If safety is compromised pharmacists and their teams must have the confidence to speak up and challenge. Unusual patterns of prescribing behaviour and unwarranted variations in clinical practice between individual prescribers cannot go unchallenged.

Senior leaders need to encourage a culture that encourages staff to speak up and challenge their organisations, a culture that enables all staff to raise concerns, encourage others to do so and to listen to – and act upon – the concerns of patients, carers and families.

Learning from Gosport

The RPS, advised by its Hospital Expert Advisory Group, is developing a discussion paper to identify how we can prevent this happening again.

But the lesson for everyone is to encourage and support a culture of patient safety in all care settings.

On 12 December, RPS is hosting a Medicines Safety Debate: Lessons from Gosport open to all health professionals. If you are interested in how you can help prevent something like this happening again or have some ideas to share come along. Find out more about the event.

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