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After Gosport: When will there be real change to better empower patients and their relatives when things go wrong?

The tragic news of more than 450 unnecessary deaths at Gosport Memorial Hospital last week, as a result of the prescription of opioid drugs without medical justification, has far reaching effects beyond Gosport and beyond discussions concerning Final Care Pathways.

Gosport Harbour
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Sarah Moore specialises in product liability and claims for groups of people who have suffered an injury because of unsafe products. She has written a number of articles on topics such as drug regulation, cigarette packaging and food safety.
The tragedy exposes the fact that patients and their families are too often disenfranchised and ignored within the current regulatory system, such that whilst dealing with their own personal tragedies they are also left to battle against a system that, too often, is unwilling to listen to their evidence and act upon their concerns.

Comments made by Bishop James Jones, Chair of the Gosport Independent Panel Inquiry last week, highlighted not only an ‘institutionalised regime’ of prescribing and administering opioids without medical justification which was permitted to continue for more than 12 years, but also that:

‘relevant healthcare organisations failed to recognise what was happening at the hospital and failed to act to put it right; how the police investigations were limited in their depth and in the range of possible offences pursued…Throughout, the relatives have shown remarkable tenacity and fortitude in questioning what happened to their loved ones.’

In his role as Health Secretary, MP Jeremy Hunt has now apologised on behalf of the Government and the NHS. In doing so, he noted that the Government now needed to answer some key questions:
  • Why was the 2003 Baker report (a first report into events concerning opiate prescription at Gosport) only able to be published 10 years later?
  • Can it be right that our system has to wait 10 years before learning critically important lessons that would save the lives of patients?
  • Why did the GMC and NMC take so long to act?
  • Why was there a 10 year delay before the doctor in question was considered by a fitness to practice panel?
  • Why did Hampshire Police Constabulary conduct only limited investigations?
  • Why did the Coroner take 2 years to proceed with Inquests?
  • Was there an institutional desire to blame the issues on one doctor rather than examine systematic failings driven by a desire to protect reputation of organisations?

Another question, not listed by Mr Hunt, but which many campaigners would wish to add is – why does this keep happening?

Why is British history littered with regulatory failures which lead to the injuries and deaths of patients as a result of treatment and/or medical products provided within the NHS?

It is hoped that the Independent Medicines and Medical Device Safety (IMMDS) Review, announced by Mr Hunt earlier this year, which is intended to look at the behaviours of regulators, manufacturers and clinicians in responding to concerns raised by patients and campaigners affected by 3 specific medical products, Sodium Valproate, Primodos and Vaginal Mesh, may go some way to answering that question.

However, the IMMDS Review does not currently have the powers of an Inquiry and some campaigners are concerned that without such powers the Review will do little to identify and rectify the systemic issues which continue to leave patients in the UK vulnerable; from Thalidomide in the 1950s; to patients in Gosport Memorial Hospital from 1989-2000; and, for example, all of the children congenitally injured by drugs such as Sodium Valproate.

Too often, within the current system, those injured by medical products in particular are unable to seek redress as a result of the expense and complexity of litigating against institutions, particularly manufacturers: The consequence is a ‘justice gap’ which means that patients and their families are let down by clinicians and then let down by regulators and the government.

Events at Gosport once again show the urgency of this issue and the fact that if the government is going to bring about substantive change to better protect patients and better support their families when things do go wrong, it is vital that the IMMDS Review recommends a thoroughgoing Public Inquiry with the power to effect an overhaul of the current consumer protection legislation which, as it stands in the UK, is ill-equipped to protect either consumers, or patients’.

For more details in relation to the Cumberlege Review process and Leigh Day’s involvement with individuals affected by Foetal Valproate Syndrome please contact v​a​l​p​r​o​a​t​e​@​l​e​i​g​h​d​a​y​.​c​o​.​u​k.

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