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The Gosport War Memorial Hospital Panel report and its implications for nursing

2018; Wiley; Volume: 75; Issue: 2 Linguagem: Inglês

10.1111/jan.13781

1365-2648

Philip Darbyshire, Robin Ion,

Palliative Care and End-of-Life Issues

"What has to be recognised by those who head up our public institutions is how difficult it is for ordinary people to challenge the closing of ranks of those who hold power". (vii) Where do we even begin? How do mere words encapsulate the full horror of the Gosport War Memorial Hospital (GWMH) report (Gosport Independent Panel, 2018) and its profound implications for nursing? Many of us thought that, in our careers, we would never again read anything as damning of health care and health services as the Francis Report; Darbyshire & McKenna, 2013; Hayter, 2013; Nolan, 2013). We were wrong. Politicians, hospitals, health services, educators, and regulators at that time were falling over each other to reassure us that "lessons had been learned," "things had changed," "new systems were in place" and that such disasters and failures "must never happen again." Thanks to the forensically detailed work of The Right Reverend James Jones KBE and his team in this review, we now know better and are unlikely to swallow such cant ever again. The substance of this report into the killing fields of GWMH is as chilling as it is damning. The report describes, in its opening paragraph, that: "The shocking outcome of the Panel's work is that we have now been able to conclude that the lives of over 450 patients were shortened while in the hospital, (p.vii) (our italics). However, this may only have been the tip of a more lethal iceberg. The report later finds that: "Taking into account the missing records, there were probably at least another 200 patients similarly affected but whose clinical notes were not found" (2.101:27 [We have followed the notation system of the report when citing it. Report section:page number]). Six hundred plus older people had their "lives shortened" while in GWMH. We invite readers to reflect on the blunt reality behind what this phrase means and to consider how they might feel if the life of their loved one was "shortened" in the circumstances we outline below. "Opioids are used to help manage the acute pain of trauma and myocardial infarction, in maintaining pain control in anaesthesia, and in the management of post-operative pain. Their appropriate and expert use in palliative care can transform patients' comfort and well-being at the end of life" (2.17:13), and, "The panel concluded that there was value in their (syringe drivers) use" (15:191) One of the numerous tragedies of GWMH and its practices are that the work of palliative care teams and many other health professionals may become so much more difficult in the future. There are already significant barriers to the optimal use of opioids in end of life care (BMA, 2017; Gardiner et al., 2012) and considerable evidence that: "the use of opioids in palliative care is suboptimal, and many patients do not receive adequate pain control at the end of life" (Gardiner et al., 2012), 206. We could hardly blame patients and relatives for recoiling now at the very mention of the words "diamorphine" or "syringe driver," thinking immediately that this is a coded professional euphemism for: "we are now going to euthanize your loved one." Patients and families will continue to plead with doctors and nurses to "please do something" or "can't you give them something" when their loved one is clearly in extreme pain, distress, and suffering. For many years now, health teams have worked tirelessly to judge, assess, and titrate the optimum doses of diamorphine and other pain relievers that would allow patients to be as pain-free as possible while also being as responsive as possible. They have also developed systems of Anticipatory Prescribing (Wilson, Seymour, & Seale, 2016; Wilson et al., 2014, 2015) designed to ensure that nurses, other health professionals, and even family members/carers can act to administer agreed medications so that patients do not endure long and painful delays before "someone can be found" to initiate or change their prescriptions. We must hope that they will continue to do so. The GWMH patients described in the Panel's report were older people, but they were not generally receiving end of life care following discussion with a ward team and with the agreement and involvement of their families. They were not patients in well-assessed and documented intractable pain from, for example, advanced cancer, that required the most powerful analgesia. Instead, they were often prescribed and given a triple cocktail of diamorphine, midazolam, and hyoscine via syringe driver for indications, "including deterioration, distress, restlessness and agitation" (2.105:28), dementia (2.9:12) or confusion (3.87:76). We are not making this up or exaggerating here. Worse, "In 29%, (of the initial group of 163 patients investigated (2.3:11) no reason was found or no clear rationale was stated in the clinical records". (2.105:28), and "In total, the Panel found evidence of opioid usage without appropriate clinical indication in 456 patients — that is, in 40% of the records that contained sufficient information" (2.101:27). Other patients whose lives were "shortened" in this way had been admitted for respite care or rehabilitation (2.96:26). "diamorphine usage in patients with a stroke was also of concern. (…) some patients admitted to the hospital after a stroke received diamorphine, with minimal evidence in the clinical notes that these patients had severe pain. Others were given opioids and, when their consciousness was unsurprisingly reduced, diagnosed as having suffered a probable stroke. However, there was no record of any examination for neurological signs of a stroke. (2.114:30)". One of us (PD) suffered a stroke in 2016 (with no debilitating sequelae fortunately) and following a 5-day stay in the hospital stroke unit, a spell of "stroke rehabilitation" was suggested, but thankfully not taken up. Stanley Carby too suffered a "mini-stroke" and was also aged 65 when admitted to GWMH "in good spirits" according to his family. He did not leave GWMH alive (Horton, 2018). Nor did any of the 13 patients from the "Initial Group" who were also in their 60s. What would have happened had I been admitted to GWMH rather than Mr Carby? Would I be here today to write this piece? "The documents that the Panel has found reveal that, as demonstrated in Table 1 at the end of the Report, during a certain period at Gosport War Memorial Hospital, there was a disregard for human life and a culture of shortening the lives of a large number of patients by prescribing and administering "dangerous doses" of a hazardous combination of medication not clinically indicated or justified" (p.vii). "Previous experience has shown that once a NHS investigation is halted by a Police investigation, then it can take years to start again. We cannot afford for this to happen" (DOH000156, p3). The records show that these remarks were prescient. The management investigation would never be restarted. The second CHI investigation was never undertaken" (4.76:96). "found a picture of care which fell well below the expected standards of nursing practice at that time. It is a picture which demonstrates a lack of concern and regard for individuals' assessed needs, as well as a lack of challenge to the prevailing prescribing practice at the hospital. It also illustrates the bravery of the nurses who raised concerns in 1991". (3.25:48) and found "sub-optimal care and lack of diligence by nursing staff in executing their professional accountability for the care delivered. Patients and relatives were marginalised and their interests became subordinate to those of the professional staff (12.21:317). What this meant in detail was that: nursing documentation was appallingly inadequate. There were often no nursing assessments or notes regarding pain, distress, medication changes, PRN medication commencement, reactions to medications given, and much more. This was NOT "bureaucratic paperwork" detailing how a patient wanted tea rather than coffee that we could all delight in railing against. These were ANY notes or records describing what would lead a patient to be started on a syringe driver loaded with diamorphine and other drugs. These were notes about ANY discussions, conversations, or planning between nurses, patients, and family about providing end-of-life care. These were ANY notes about how a patient was reacting or responding to major opiate mixtures. These were ANY notes about why a patient's diamorphine dose should be raised or even doubled, by nursing staff, to anywhere between the allowed "anticipatory prescribing" range of between 20–200 mg (3.12:45). These were ANY notes about how ANY nurse had stepped in at ANY time to "challenge the prevailing practices on the wards" (3.13:45). Nurses failed at almost every possible juncture to provide individualized care, to protect patients, to keep the most rudimentary of "good records," to work as a trusted partner with families and relatives, to challenge or question clinical or pharmacological decisions based on sound clinical judgement, to escalate safety and care quality concerns to the point of action, to manage services with the patient as the priority and central focus, and to think reflectively and critically about what was happening to their patients and at their hospital. The NMC, perhaps predictably, given the findings of other inquiries such as Morecambe Bay (Kirkup, 2015), took 10 years, hallmarked by: "the almost complete lack of communication between the NMC and the families" (7.66:229) to "decline to proceed in respect of all the allegations against the nurses concerned" (12.25:318). "However, the records also show that nurses in the hospital administered the drugs and continued to do so for many years, although the link with the pattern of deaths would have been apparent to them. Within the professional standards which applied at the time, the nursing staff also had a responsibility to intervene and challenge the prevailing practice on the wards" (3.13:45). Likewise, almost every official body it seems, from management, health services, police and legal services, regulators and more exhibited an "organisational deafness" (Jones & Kelly, 2014) towards any concerns or complaints raised by either staff or relatives. Exactly how loudly any "whistle" would have to be blown to penetrate this wall of inertia and self-interest is unknown. There is no ambiguity here or ideological battle between individual and systemic or organizational responsibility (Darbyshire, 2014, 2015). This is not a case of "choosing" who or what is to blame and apportioning all responsibility to either individual nurses, doctors, managers, or whoever or to some nebulous thing called "the system." Both are culpable, and neither can be exclusively singled out for blame to the exclusion of the other. As Jones and Kelly note, (Jones & Kelly, 2014) it is not enough to complain that in our health services some do not "speak out" when there are formidable cultural and organizational forces determined neither to listen nor to hear. "Being accountable also means being liable: the registration bodies for doctors and nurses should make it clear to their members that, if there is finding of serious professional misconduct in the treatment of patients at the end of life, the normal sanctions for professional misconduct apply". (2.13:37) (Neuberger, 2013) "A number of nurses raised concerns about the prescribing of drugs, in particular diamorphine. In so doing, the nurses involved, supported by their Royal College of Nursing branch convenor, gave the hospital the opportunity to rectify the practice. In choosing not to do so, the opportunity was lost, deaths resulted and, 22 years later, it became necessary to establish this Panel in order to discover the truth of what happened. The documents therefore tell a story of missed opportunity and unheeded warnings." (Conclusion: 9) There is, however, a problem with the "nurses' bravery" narrative. It is certainly true that in many, many contexts and organizational cultures, it does take courage to confront managers, doctors, or other more powerful groups, to challenge existing practices or to question the clinical judgements of other professionals, especially if they are more senior. This, however, cannot be seen as a matter of individual nurses being brave or courageous. Bravery may be seen as a characteristic of some, but not all nurses, as an option to be exercised only by the fearless. What do we say to the nurse who argues that he/she is "not brave," who feels that they "cannot take the risk of confronting or questioning poor practice," who "doesn't like to upset colleagues," who cannot afford to challenge more powerful figures because they "need their job to pay the mortgage"? Are they to be allowed to slip off the hook of professional obligation because they are not "brave enough"? Professional responsibility cannot be sloughed off so easily. This is crystal clear from guidance provided by the regulator which requires nurses to prioritize people, practice effectively, preserve safety and promote professionalism and trust. To use the words of the NMC, these things are: "(…) not negotiable or discretionary (…) They are the standards that patients and members of the public (…) expect from healthcare professionals" (NMC, 2015). There is nowhere to hide. As a Registered Nurse you are responsible for your nursing, your practices, for your actions and omissions, and for their impact on patients and colleagues. To be a registrant—and we emphatically include nurse managers and leaders in this—you must accept the possibility that difficult and demanding situations will arise which will stretch your capacity and challenge your preferred ways of practicing or managing. The regulator, the public and hopefully, your conscience, expect that you will approach these situations with a commitment to human dignity, professionalism, critical awareness, and a moral compass that, with some very notable exceptions, appeared absent at GWMH. If you do not want such an onerous responsibility for people's lives and well-being, you need to reconsider nursing and/or health service management as your career or occupation. If justice delayed is really justice denied, then the GWMH families and relatives have suffered denial on an epochal scale as: "it is over 27 years since nurses at the hospital first voiced their concerns. It is at least 20 years since the families sought answers through proper investigation" (12.2:315). This report has shown the bankruptcy of organizations' "proper channels" that can only be seen now as a self-serving panoply of official processes designed primarily to silence, deflect, delay, and deter. Health managers and leaders who insist on staff pursuing concerns via such "proper channels" can no longer be under any illusions as to what they are mandating. Educators must surely also question "ethics teaching" in nursing, management, and professional development programmes. Years of having well-meaning ethicists listing "ethical principles" have ill-prepared nurses and managers for the realities of today's corporatized health services where "damage limitation" and "reputation management" can be so readily seen as more pressing concerns that patient safety and well-being. The question facing all nurses is: Will this report of the deaths at GWMH, the actions and inactions of nurses, and other professionals involved and the systemic failures at every management and regulatory level be any kind of "tipping point"? (Chan Kim & Mauborgne, 2003). Many of us believed that The Francis Report (Francis, 2013) would be the catalyst for significant change in individual and organization practices, but we were wrong. We surely cannot afford be wrong again. Having a "no-blame" (Catchpole, 2009; Wachter, 2013; Walton, 2004) culture is laudable but must not become synonymous with a "nobody is responsible" culture. Creating such a culture where health professionals have patients, families, and those we serve as our centre of gravity and not the organizations, we work for or the professions that we belong to will be a seismic shift. For the sake of the others who will place their lives and well-being in our hands, we had better be up to the challenge. This work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. No conflict of interest has been declared by the authors.