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Hospital Found Responsible For Deaths From Morphine Overdose

Posted Apr 21 2009 11:49pm

An inquest into how 10 elderly patients died at a Portsmouth hospital has reached the verdict that three of them accidentally given morphine overdoses, which ultimately resulted in their deaths.

A further two patients also had injections of the drugs which helped to speed their deaths but did not cause it, where the jury found the dose appropriate. The other five patients were found to not have died as a result of the drugs they were given.

The verdict yesterday marked a concrete result in a set of inquiries by police and the NHS that have been on going for ten years into around 200 deaths at Gosport War Memorial Hospital in the late 1990s.

Relatives of the deceased had maintained for some time that morphine overdoses were responsible for the deaths. Talking after the verdict was passed, they said the jury concluded large amounts of the strong painkiller had been prescribed “without justification or logic”, and the now waited to find out how the General Medical Council would respond.

The hospital in question has been receiving complaints for over ten years. Relatives referred to a “death ward” in the hospital where their family members were supposed to be recuperating but ended up dead instead. The staff’s response to these complaints was that the patients were already dying from terminal illnesses and only there for palliative care.

Hampshire Police were called in to investigate but they did not take any action. The complaint was passed on to the Commission for Health Improvement, the NHS watchdog (now the Care Quality Commission), which in 2002 determined there was a breakdown in patient care including irresponsible prescribing and staff supervision but there was an improvement in the situation. Due to the publicity that emerged from he report, many more families spoke out abut similar concerns and Hampshire Police re-opened the case.

Out of 92 deaths, just ten sample cases went to the Crown Prosecution Service, however it was concluded there was insufficient evidence to prosecute. The cases were then referred on to the Portsmouth coroner, who required special permission from the Justice Secretary, Jack Straw to make inquests into the deaths due to the fact seven out of 10 of the bodies had been cremated. This is due to the law which states an inquest can only be held when the body is present, except in exceptional circumstances.

Chief Medical Officer for the Government, Sir Liam Donaldson, asked Professor Richard Baker (responsible for exposing Harold Shipman) to review death statistics at the hospital in 2002, however the results were not publicised.

After a month long inquest which finished yesterday, the jury concluded that three patients  – Robert Wilson, Elsie Devine and Geoffrey Packman - were given a medication that was inappropriate for their condition. However, evidence suggests the overdoses were not given on purpose as the morphine was been given for therapeutic reasons.

Professor Baker, who took charge of Mr Wilson’s case, who died prematurely at the age of 74 after being treated for a broken arm, told the jury there was a significant chance he would have survived were it not for the morphine.

With Geoffrey Packman, 66, his heart condition was being treated by staff, but the fact he was suffering from internal bleeding went unnoticed. An expert in palliative care, Professor Andrew Wilcock stated that “excessive amounts” of morphine were given.

With the other two patients  – Elsie Lavender and Arthur Cunningham – the jury found morphine prescribed was deemed appropriate for their condition.

Dr Jane Barton, a GP working at the community hospital part time was the only doctor investigated as part of the inquest. She was in charge of the wards where the patients died, although she did not face any charges, She had implemented a system whereby nurses were allowed to up the dose of painkillers, like morphine, without a doctor needing to be present.

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