Gosport Independent Panel — House of Lords, 2018-11-22
Topic: Health
Margaret Eileen Joyce Wheeler (Labour, Centre-left): My Lords, I thank the Minister for reading out the Statement updating the House on government actions since this appalling tragedy was reported to the House in June. As the Statement says, the Gosport report was "truly shocking", and once again our thoughts, sympathies and condolences go out to the families of the 456 patients whose lives were shortened. Those families campaigned for so many years to find out what happened. We also again pay tribute to these relatives for their courage, tenacity and persistence in seeking the truth, and to the panel, with particular thanks for the calm and compassionate leadership of the chair, Bishop James Jones, for its unstinting work in uncovering the injustice and for listening to and hearing the families’ concerns It is important to remind ourselves of the panel’s conclusions. First, there was a disregard for human life and a culture of shortening the lives of a large number of elderly patients. Secondly, there was an institutional regime of prescribing and administering "dangerous doses" of a hazardous combination of medication not clinically indicated or justified. Thirdly, relatives were constantly let down by those in authority in the hospital when they complained. Fourthly, senior management, the local constabulary and politicians, the coroner system, the CPS, the GMC and the NMC all failed to act in ways that would have better protected patients and relatives We welcome the commitment to strengthen protections for whistleblowers and for new legislation to compel NHS trusts to report annually on how concerns raised by staff have been addressed. Has a detailed programme of work for this been drawn up? When does the Minister envisage that legislation on these new powers will be introduced? However, much of the Statement today is about work in progress on the actions and measures that were announced when the report was published, and it is important that we receive regular updates in the future. In his June Statement, the Minister referred to the introduction next April of medical examiners to ensure that every death is scrutinised by either a coroner or a medical examiner, and yesterday’s Statement repeats this commitment. Can the Minister advise the House on progress on this? If they are to be employed by acute trusts, how will their independence be maintained and how will they link into the mortality reviews and the Learning from Deaths guidance? Has consideration been given to basing them in local authorities so that their remit can be extended to primary care, nursing homes and mental health and community trusts? What additional resources are being provided to fund these new posts When the report was published, the House welcomed the urgent establishment of a hotline and of counselling being made available to all those who had lost loved ones and were affected. Are these important provisions still available and will they continue to be provided? What further support is being provided? Also, in addition to the 456 patients given opiates without appropriate prescribing or as a result of the prescribing practices at the hospital, sadly, 200 more patients were referred to in the report whose clinical notes or medical records had gone missing. The panel considered that these patients had been similarly affected. What progress has been made by the workstream set up to further investigate this appalling situation? How many more cases have been substantiated as a result of this On the question of oversight of the use of opiates in the NHS, is the Minister satisfied that it is now tight enough to prevent incidents such as this happening again? We welcome the promise of a further review on how patient safety can be improved when prescribing and dispensing medicine, aimed at detecting inappropriate prescribing. Can the Minister give us further details of how this review is to be conducted, including the full remit and timescales In June, the Minister also promised a "fresh impetus" to moving forward on the need to streamline professional regulation following the report’s condemnation of the inadequacies of the GMC and NMC regulators who failed to act in ways that would have better protected patients and relatives. What progress has been made on this work Finally, we come back to the key issue of patient safety and the need to build a patient safety culture in the NHS. Does the Minister consider that additional legislation is needed to keep patients safe? Is a new independent body now required to pick up and take forward the remit of the former Patient Safety Agency, so unwisely abolished by the Government The Statement ends by underlining the cultural change that needs to be driven across the NHS to achieve openness, transparency and learning rather than blame and the cover-up of mistakes and incidents, and of course we agree with that. For all the awfulness of its findings, the Gosport panel report has managed to ensure that the carers and relatives of loved ones and staff have been listened to and heard. We on these Benches pledge our full support for the measures which will ensure that what happened at Gosport never happens again.