Chapter 2: Prescribing and administration of drugs and the deaths that resulted
Conclusion: what is added to public understanding
- By the time of the events at Gosport War Memorial Hospital examined in this Report, the principles of safe and effective use of opioids, midazolam and other drugs in both palliative and non-palliative care were clearly set out in authoritative international and national guidance. These were also reflected in local guidance issued in the Wessex Region of the NHS. These had been adopted by Portsmouth Hospitals NHS Trust which provided medicines and associated pharmacy services to Gosport.
- The Commission for Health Improvement report, using the Trust’s own medicines usage data, noted the excessive use of diamorphine and midazolam which reached a peak in 1998/99. Over that period, the Commission for Health Improvement noted that Dryad, Daedalus and Sultan wards used 1,617 doses of diamorphine and 1,680 doses of midazolam. With a patient population that was in the main not admitted for palliative or end of life care, this was excessive. Even superficial monitoring of pharmacy data should have sounded alarm bells.
- The Panel has found that the records show that 456 patients died where medication – opioids – had been prescribed and administered without appropriate clinical justification. The review of evidence conducted by the Panel suggests that, taking into account the missing records, there may have been a further 200 such deaths, bringing the overall total to around 650.
- The Panel’s analysis reveals that the dose range prescribed was too wide, completely contrary to national guidance, and ignored both the British National Formulary and the Wessex guidelines in operation at the time.
- The practice of prescribing and administering drugs at the hospital conflicted with the national and local guidance that applied at the time.
- The Panel found that survival was short once continuous diamorphine had been started, less than three days in the majority of relevant cases, and this was equally true in those who had received diamorphine without appropriate clinical indication.
- Pre-prescribing opioids has a part to play, after careful evaluation, in the palliative care of patients assessed as being at the end of their lives. This is very different from pre-prescribing opioid medication for patients who have been assessed as requiring a period of respite care. The Panel therefore found it particularly surprising to see this practice extended to a few respite care patients, albeit frail, whose stay at the hospital was elective, that is to say planned and predominantly for a short period, and to patients admitted for rehabilitation.
- The Panel’s analysis shows that over half of patients whose records were complete enough to assess were given a combination of three drugs via syringe driver: diamorphine, midazolam and hyoscine. There was little evidence that any consideration went into assessing what combination of drugs was best for an individual patient. Agitation and restlessness could have been managed with midazolam alone. The combination of all three drugs would cumulatively depress consciousness and respiration. Diamorphine itself can cause agitation. The majority of patients given the combination died on the same day or the next day.
- Diamorphine has approximately three times the potency of oral morphine. Accordingly, to maintain dose equivalence when making this switch, the dose of diamorphine should be one-third of the dose of oral morphine over a 24-hour period. This is spelled out in the relevant guidance, the British National Formulary.
- Despite the guidance, there is little evidence in the documents seen by the Panel to suggest that, when switching a patient from an oral opioid to a subcutaneous opioid, the conversion guidance was acknowledged and applied. In 72% of cases, the dose of subcutaneous diamorphine exceeded the equivalent dose at the time the switch was made.
- There is a pattern of deaths at the hospital, which shows a marked increase from 1993, peaking in 1998 and then decreasing sharply to resume the previous annual level by 2001. There is no evidence to support this being the result of a rise in the number of more seriously ill patients or those requiring end of life care.
- The available documents do not provide an explanation which would account for the high level of deaths recorded as due to bronchopneumonia, particularly as the underlying cause of death.
- The number of deaths ascribed to bronchopneumonia as the underlying cause followed the same pattern of increase and decrease over the 1990s as both the use of opioids without appropriate clinical indication and the number of deaths overall.