Gosport War Memorial Hospital: the report of the Gosport Independent Panel

Bishop James Jones · work from 2014 · published 2018

What this was

Independent panel report on the prescribing of opioids at Gosport War Memorial Hospital. It found that the lives of patients were shortened, and that families had raised concerns for years without being heard.

Why it sits in the hub

It is the modern case study of a closed prescribing culture, missing governance of controlled drugs, and institutions that defended themselves against families. Shipman's lessons had not reached this ward.

Findings

Finding 1
Opioid prescribing shortened lives. Nurses and families raised concerns that the organisation did not act on.
Listening to patients and families Medicines and devices Speaking up
Finding 2
Successive investigations failed to establish what had happened.
Learning from harm Regulation and oversight

Recommendations in this hub

Paraphrase of the public recommendations, not the official text.

1Partly doneNHS trusts
Govern controlled drugs so that one clinician's practice cannot drift without being seen.
Data and early warning Medicines and devices
2Partly doneGovernment
Give families a route that is independent of the organisation they are complaining about.
Complaints and redress Listening to patients and families