Dr Jane Barton exploded into the media recently over findings of a damning report condemning her practice of routinely prescribing opiates for patients who didn’t need them. This took place at Gosport Memorial Hospital in Hampshire between 1988 and 2000. It found that she was responsible for 456 deaths, but perhaps as many as 650. This is hard to fathom. Not only the scale but the fact it had been allowed to go on for so long when families and staff at the hospital raised concerns.
One of the whistleblowers, an auxiliary nurse reported her concerns to police after seeing a newspaper report in 2001 regarding the death of one of the hospital’s patients. She and a colleague were concerned over the treatment of another patient, an elderly man, who was at the hospital convalescing but was otherwise to all accounts in good physical and mental health. But he was found to be difficult with staff and then later to her horror he was found being infused with opiate and in an unconscious state. He died several hours later.
Julia Hurlbut, Director and Head of Medical Negligence at Jackson Lees, comments:
Diamorphine, the opiate prescribed by Dr Barton, is the strongest painkilling drug on prescription and if given in sufficiently high doses can cause respiratory failure. This is what happened to Dr Barton’s patients.
More than half of the patients she permitted the administration of diamorphine to were not even noted to be in pain.
A whistleblower to the government enquiry told the Sunday Times (24 June) that the syringe drivers, which were used to infuse the diamorphine were unsafe. The purpose of the syringe drivers was to alleviate staff from having to provide repeated injections.
One of the problems with the drivers is that there were two types in use – one, the Graseby MS 26 which infused the drug over a 24 hour period and the other, the Graseby MS 16A which infused the drug over an hour. Both looked very similar to one another and as a result administration errors occurred meaning that a patient could receive a 24-hour dose in one hour if the wrong driver were used. Not all hospitals were using these syringe drivers and many only used one type to avoid confusion. However, both drivers were said to be in use at the Gosport Hospital.
The British Medicine Regulator deemed the syringe drivers unsafe in 1995. The NHS issued a notice recommending that hospitals replace the drivers in 2010 but did not recall them. Instead their use was not disallowed until 2015. The Gosport panel responded to the Sunday Times to say that these allegations are unfounded and without merit or support.
Over the years my clients have made complaints to their hospital or GP over concern about their care only to receive a response, which often brushes over the real issues. In many such cases once we have obtained and scrutinised the medical records and obtained an independent medical expert opinion we find that there is evidence of negligent care, which has caused injury.
The scandal over Dr Barton’s prescribing at Gosport Hospital might have opened a can of worms for the NHS as it has highlighted critical errors in how these drugs were administered. Of course the actions of Dr Barton have been condemned and the story hasn’t ended there. The Criminal Prosecution Service are investigating the report’s findings with a view to deciding upon criminal charges.
But also importantly it raises questions about the culture within the NHS when concerns are raised by patients, their families and staff.
Julia will be our adviser at the drop-in clinic on Thursday 5th July.
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