The Royal Pharmaceutical Society set up a Medicines Safety Debate entitled ‘Lessons from Gosport’ in December 2018 to share learning from the Inquiry. It brought together key people responsible for the safe and appropriate use of opioids. The panel comprised the Head of Medicines Optimisation at the CQC, a national investigator from the Healthcare Safety Investigation Branch, the professional lead for non-medical prescribing from the RCN, London’s Controlled Drugs Accountable Officer and the President of the British Geriatrics Society. It was also attended by the CEOs of the General Pharmaceutical Council (our regulatory body) and the Royal Pharmaceutical Society (our professional body). It was attended by around 70 people, mainly pharmacists, many who were Medicines Safety Officers for a trust.
It is acknowledged that at least 450 people are thought to have died after the administration of inappropriately high doses of opioids over 12 years, and there was no evidence that the nurses and pharmacists working there had formally challenged prescribing practices despite having concerns. The report stated: “One of the most difficult things to understand about these events is why so many people were prescribed and administered drugs that were not clinically indicated in quantities sufficient to shorten their lives”.
Challenging prescribing practice
Since 2005, when the Shipman Inquiry was published, increased monitoring and networking in Local Intelligence Networks has enabled healthcare professionals to share concerns and good practice but there is no room for complacency. The debate focussed on how we currently challenge prescribing practice and monitor it effectively, and ended with reflections and next steps.
A hospice response
What happened at Gosport was mainly due to there being no routine monitoring of safe and effective prescribing. Hospice and palliative care clinicians have specific expertise in the judicious use of opioids towards the end of life, and patients are monitored more frequently and by a multi-professional team. We also have access to formularies and guidelines for opioids, so it feels that our response needs to be proportional. However, our patients are mainly frail and elderly and it is always good to review our practice, so the following areas could form the basis of the response for a hospice:
- Review current guidelines to ensure they contain specific guidance for frail elderly patients with specific attention to anticipatory doses
- Ensure those who write the guidelines are fully representative of the healthcare professionals involved and, if possible, include a consumer of the service
- Ensure the guidelines are clear and that all staff know about them
- Ensure instructions for the use of anticipatory medicines in the home setting are clear.
Possible areas for audit include:
- Anticipatory prescribing
- Review of unexpected deaths and examination of opioids prescribed and administered
- Opioids covered in staff training and at induction
- Use of naloxone – make it a reported incident and investigate occurrences.
Final messages included the need for Controlled Drug reports, such as those sent to the local LIN, to be shared at board level, ensuring staff are aware of the role of the CD Accountable Officer and that they can report concerns confidentially.
In support of these topics, Ashtons has a training package for Controlled Drugs with an online version in production. We can also provide opioid conversion charts and ‘Suggested Standard Initial Subcutaneous Drug Prescribing’ for community patients with a separate one for frail elderly patients. For more information please contact your visiting pharmacist.