Patient safety

Regulator to review Gosport findings following inappropriate opioid painkiller doses

The only pharmacist named in the Gosport report removed herself voluntarily from the pharmacists’ register in 2012.

opioid overdose


An independent panel appointed to investigate the opioid painkiller-related deaths said Portsmouth Healthcare NHS Trust’s Drugs and Therapeutics Committee did not challenge the prescribing practice at the trust

The pharmacy regulator has said it will consider whether to take any action following the report into Gosport War Memorial Hospital, where at least 456 patients died after being given inappropriate doses of opioid painkillers.

The General Pharmaceutical Council (GPhC) confirmed that its next council meeting in July would be updated on “initial actions” the regulator is taking following the report’s publication, and in a statement it said: “We are carefully considering the report and any necessary learning or actions for the GPhC.”

The GPhC has also confirmed that the only pharmacist named in the Gosport report removed herself voluntarily from the register in 2012, and it said it had no jurisdiction to investigate pharmacists who were no longer on the professional register.

Jean Dalton was employed by Portsmouth Hospitals NHS Trust, which had a service level agreement to provide pharmacy services to the hospital in Gosport from 1994. Before that date, the pharmacy was part of Gosport’s outpatient department.

The service level agreement contract was managed by the Portsmouth trust’s chief pharmacist, who was unnamed in the panel’s report, and who had overall responsibility for the service. The delivery of the service — including regular ward visits to review the drug charts and to check the drug stock — was down to Dalton, according to evidence given to the report by a ward Sister.

The independent panel set up to investigate the patient deaths that occurred between 1988 and 2000 did not single Dalton out for criticism in its , which was published earlier in June 2018.

But the panel did report that there was no evidence that pharmacists and the then Portsmouth Healthcare NHS Trust’s drugs and therapeutics committee challenged the prescribing practice at Gosport, despite documented evidence of the quantities of opioids used on the wards and that patients “in the main” did not require palliative or end-of-life care.

Jane Barton, clinical assistant and GP, who oversaw the practice of prescribing on the wards identified by the panel, is the only person to have faced disciplinary action to date. She was found guilty by the General Medical Council of serious professional misconduct; however, she retired and no prosecutions were brought.

Breaking her silence since the report was published,  on 27 June 2018 that his wife maintained she was “a hardworking, dedicated doctor doing the best for her patients in a very inadequately resourced part of the health service”.

Meanwhile, pharmacy leaders in Hampshire this week said they hoped the profession today had more confidence and courage to speak out if concerned about prescribing practice.

Deborah Crockford, Community Pharmacy South Central local pharmaceutical committee chief officer, said pharmacy involvement in leadership programmes such as the Mary Seacole scheme would help enhance the profession’s sense of equality with doctors.

She told The Salvadore: “There has always been this culture that ‘doctor knows best’, which has been reflected in the attitude of nurses and everybody else really.”

Citation: The Salvadore DOI: 10.1211/PJ.2018.20205088

Readers' comments (1)

  • The GPhC say that Ms Dalton 'removed herself from the register’. Do they mean ‘retired”. If so, why be pejorative?

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