In June 2018 the Gosport War Memorial Hospital Report (GWMHR) was released. Themes within these findings are familiar, a reflection of past Inquiries into healthcare failures in acute and aged care across the globe. What happened at GWMH?
From as early as 1988 concerns had been raised by staff regarding the use of diamorphine via a syringe driver without clinical indication causing patients to die prematurely. These concerns were classified as – a small number of staff making waves – internal investigations effectively silenced those raising the alarm. Twenty-two years later a panel was established that examined more than 2,000 deaths at the hospital between 1987 and 2001, finding that at least 450 older people had their lives shortened:
‘… as a consequence of the prescription and administration of opiates, often given in combination with other powerful sedatives in the absence of any demonstrated clinical need. It is thought that “there were probably at least another 200 patients similarly affected but whose clinical notes were not found” (GWMHR 2018).
These patients were not in extreme pain nor were they for end of life care with many admitted for respite or rehabilitation. The ‘prescribing policy’ gave authority to the nurses to administer PRN medication across a wide dose range, eg. 20mg-200mg of diamorphine, resulting in inappropriate high starting doses for continuous periods of time which became ‘the culture and norm’ for practice on wards in GWMH. Few patients survived this regime for more than a few days. The panel concluded that there was a disregard for human life (GWMHR 2018).
It was clear that both clinicians, management and a number of institutions were aware of what was happening at GWMH and failed to challenge these behaviours, placing the reputation of the organisation and the professions ahead of patient safety and welfare. In this case such a failure led to tragic consequences. There is no doubt that challenging a colleague’s practice or a workplace culture is complex and can be confronting. However, it is critical that we learn how to do this constructively and professionally. But it is also important that we learn how to respond professionally to such challenges.
Take a moment to think about how challenges and questions on norms are dealt with in your workplace. Is there a culture that welcomes challenges and views these as opportunities to reflect on current practice and make improvements or do we silence those who question the current norm? If it is the latter Darbyshire & Ion (2018) made the following comment:
‘If you are the kind of nurse, educator, dean, doctor or other professional who deems such questions or challenges from students or colleagues to be a form of insult, disloyalty, insubordination or questioning of authority and who reacts with indignation, petulance, anger, retribution or worse, then either change your attitudes and behaviour, or get out of healthcare or health professional education now, for you are part of this seemingly intractable problem that is costing patients their lives. We simply cannot afford to have you around anymore. You are far too dangerous to keep.’ (p 133)
A sobering thought. Furthermore, in the GWMH case it was held that the nurses should not have been made the sole arbiters of when to begin continuous opioids and at what doses as it was beyond their scope – which is true. However, as Darbyshire & Ion (2018) point out – these were registered health professionals who should not allow themselves to be ‘put in any positions’ that conflict with their professional responsibilities. Their job is to challenge and question these ‘positions’ and to refuse to adopt any actions or inactions that may cause patients harm or death.’ (p 133).
It is important that practitioners acknowledge that they are accountable for their own actions – whether they choose to take appropriate action or remain silent. It is important for managers to realise that staff need their support to do so.
Gosport War Memorial Hospital. The Report of the Gosport Independent Panel June 2018. https://www.gosportpanel.independent.gov.uk/
Darbyshire, P., & Ion, R. 2018. The lessons of Gosport for nursing education. Nurse Education Today 70 130–135
An expert in the field of nursing and the law Associate Professor Linda Starr is in the School of Nursing and Midwifery at Flinders University in South Australia