Chapter 2: Prescribing and administration of drugs and the deaths that resulted

The documents show that Staff Nurse Anita Tubbritt, Staff Nurse Sylvia Giffin and Nurse Beverley Turnbull acted to alert authorities at Gosport War Memorial Hospital (‘the hospital’). Their concern was the medication – principally diamorphine given by syringe driver – prescribed for and administered to patients in their care.

The evidence available suggests that some families also voiced concerns about the drugs administered, as well as wider concerns. The Panel has seen references to individual complaints, mainly informal rather than formal. In one case a complaint dates from 1982, while other complaints date from 1989. The lack of documentation in the intervening period has prevented the Panel from assessing the pattern of any complaints made at that time, or the response to those complaints. Of the families who subsequently contacted the Panel, around two-thirds said that their primary concern was indeed the medication; that is, diamorphine injected by syringe driver and a number of other drugs prescribed for and administered to their loved ones.

 The Panel initially examined the case notes for 163 men and women who were patients on Redclyffe Annexe, Mulberry Ward, Sultan Ward, or one of the male or female elderly care wards, and, after 1993, Daedalus and Dryad wards at the hospital. These were patients whose deaths were investigated as part of Hampshire Constabulary’s Operation Rochester or whose families came forward to the Panel and asked for their relative to be included in its review. They are the Initial Group of patients.

The Panel was deeply concerned by what it found and therefore extended its analysis to cover a greater number and a wider range of patients who died at the hospital between 1987 and 2001, where the Panel had access to their medical records and death certificates. These are the Wider Group of patients.

This chapter explains the drugs that were prescribed at the hospital, the law that applies and the clinical guidance that should have applied. The chapter goes on to set out the Panel’s analysis of the drugs as they were prescribed and administered and sets out eight key ‘findings’. By ‘findings’ the Panel is revealing what has been found in the documents provided.

 The Panel found that, as well as expressing the same primary concern, in many instances the families’ recall was striking. Relatives, and sometimes patients themselves, could not understand why powerful painkillers had been given in high doses and then escalated further, increasing sedation; in some cases, lives were shortened.

This same theme emerges time and time again from the families’ experience. For example, the daughter of one patient discovered that a syringe driver had been inserted. She queried this because she knew her father wasn’t in pain and didn’t need it, but ward staff were dismissive, telling her she was not a nurse and that they were the professionals. She was furious and called her father’s GP, who arranged for the syringe driver to be taken out and for her father to come home.

Another patient was admitted for respite care but deteriorated and became confused during his stay. Staff asked permission to give him diamorphine but his daughter refused, as he was not in pain. However, her mother later agreed and he was started on diamorphine by syringe driver. He died the same day.

A man admitted for dementia was started on a diamorphine syringe driver. Staff asked his son for permission and he gave it but felt there was no explanation of what it meant to be given diamorphine. The dose was doubled and his father died five days later. His son felt that the diamorphine effectively killed him.

These are only three allegations from the families who have been in touch with the Panel. There are many more. For example, some families told us of their concerns that medications they believed to be essential had been discontinued during their relative’s stay at the hospital. Powerful though these stories are, the Panel has looked beyond them at the detail of the cases. The skilled, safe and effective use of powerful analgesics and other sedative drugs can have an enormous positive impact on patients’ comfort and well-being. But, used wrongly, they can also cause great harm. In other words, the medication prescribed at the hospital would have been appropriate where that medication in the dosage prescribed and administered was justified by the patient’s condition; that is to say where it was ‘clinically indicated’. In order to understand what the documents reveal about the prescribing and administering of drugs that were not clinically indicated, it may be helpful to explain the therapeutics of strong analgesics and related drugs.

This chapter therefore gives an overview of: the drugs used at the hospital and their benefits, risks and place in therapy; the principles that underlie their safe prescribing; the standards and guidance on prescribing that were extant locally, nationally and internationally; and the governance, prescribing and record-keeping processes that were in place at the hospital at the time. This chapter concludes with the Panel’s examination of how these drugs were used at the hospital and the deaths that resulted.