On 30th June 2018 the Gosport Independent Panel published its report on what happened at Gosport Memorial Hospital between 1987 and 2001(1). As Jeremy Hunt said, its findings can only be described as truly shocking. The Panel found that during this period the lives of over 450 patients were shortened by clinically inappropriate use of opioid analgesics, with an additional 200 lives also likely to be have been shortened if missing medical records are considered.
The Panel found that during this period the lives of over 450 patients were shortened by clinically inappropriate use of opioid analgesics
The audit found:
- Opiates had been administered to virtually all patients who died under the care of the Department of Medicine for Elderly People at Gosport, and most had received diamorphine by syringe driver
- Opiates were administered to patients with all types of conditions, including cancer, bronchopneumonia, dementia, and strokes
- Opiates were often prescribed before they were needed – in many cases on the day of admission, although they were not administered until several days or weeks later
- In many records, evidence of a careful assessment before use of opiates was absent, and the stepped approach to management of pain in palliative care had not been followed.
Opiates in hospices
Hospice practice is to use opiates when other analgesics have not been sufficient to treat pain as recommended by the long-established World Health Organisation STEPwise approach as mentioned above. We understand that they need not be given routinely to all patients, as not all patients have pain. Careful and regular reviews ensure patients have their medicines prescribed in line with their individual need and we are cautious with initial doses, often starting with 1 to 2mg morphine doses in frail elderly patients or those who are opiate naïve. Although opiates may be prescribed in advance of their need – to enable prompt responses to new or worsening symptoms when a prescriber is not immediately on hand – experienced healthcare professionals will discuss initiation before use, and can also advise generalists in doing the same; for example, a District Nurse looking after an end-of-life patient at home will usually call the local hospice team for guidance on setting up a syringe pump.
The report has been a very long time coming due to the complexities of professional and police investigations, and since that time, important changes to our management of opioids have been made. These include implementation of the recommendations of the Shipman Inquiry to create Local Intelligence Networks and Accountable Officers to whom concerns can be raised. Reports on every organisation’s incidents involving Controlled Drugs are submitted quarterly and individual organisations have their own structures for monitoring. The CQC now oversees the safe management of Controlled Drugs and produces an annual update with key recommendations.
Several experienced clinicians have written about the implications of the reprehensible practice in Gosport. In palliative care we have long worked to assure patients, families and other healthcare professionals that when opioids are used according to the accepted guidelines, they are no more dangerous than other medicines. We have always been aware of the potential for addiction to opioids due to their effect on the endorphin ‘reward’ system but experience shows that people using them for pain do not become ‘addicted’ but simply benefit from their effects and need to continue to use them regularly when they control constant pain. We know that if we increase the dose in small increments if the pain increases, people can remain alert and more comfortable and respiratory depression is very rare. We now know that opioids have long-term effects on fertility and are not effective for many chronic pains and so their use is being strongly discouraged for people with issues like back pain. With that message, as well as the newspaper headlines in the UK and USA about abuse, it is easy to see why people are still afraid of morphine.
Syringe pumps have received a lot of attention in these news stories too. They are just a delivery method of an appropriate medication for pain. The older models did not have many safety features and used an unfamiliar measurement of the length of the column of liquid in the syringe, rather than volume, and any piece of equipment requires training. It is not hard to imagine how mistakes may have occurred back when there were two syringe driver models in use, designed to deliver medication over either 24 hours or one hour, especially when used by generalist healthcare professionals only occasionally. The newer pumps have more logical measurements and safety checks but at £1,500 per pump it wasn’t possible for most establishments to replace old with new immediately.
We need to assure our patients and their families receiving hospice care that opioids are both safe and effective for use at the end of life. When you read into the articles on the report, the authors usually have the foresight to mention this (see this great example).