After receiving overdoses of unnecessary painkillers, more than 450 patients died at Gosport War Memorial Hospital in England, an investigative panel revealed June 20, according to The New York Times.
Six things to know:
1. The panel determined hospital officials failed or refused to use proper oversight on these drug practices for years, dismissing concerns of family members and nurses. From 1989 to 2000, physicians at the small British hospital, including one specific physician, regularly prescribed heroin and other opioids for patients who were not experiencing pain. They also prescribed these powerful painkillers for patients who should have been prescribed milder drugs. While many of the patients were elderly, most were not seriously ill.
2. "Whereas a large number of patients and their relatives understood that their admission to the hospital was for either rehabilitation or respite care, they were, in effect, put on a terminal care pathway," Bishop Jones, who led the Gosport Independent Panel, wrote in the report. The report did not detail whether these physicians were incompetent or whether they had bad intentions, The New York Times reported.
3. The panel also found a number of failures by hospital administrators seeking to protect the facility's reputation, pharmacists who did not warn others about hospital staff's excessive use of these drugs, police officers who could not properly conduct a medical investigation and government regulators who did not take the complaints of families and nurses seriously.
4. The panel found medical records for more than 1,000 patients who died at the hospital, and "found evidence of opioid usage without appropriate clinical indication in 456 patients," or more than 45 percent. "Taking into account the missing records," the report said, "there were probably at least another 200 patients similarly affected but whose clinical notes were not found."
5. Many of the cases involved one physician, Jane Barton, who had developed a pattern that was followed by other providers, the report said. Dr. Barton was censured in 2009 after a disciplinary panel investigated a few of those cases, and although she retired, she was not prohibited from practicing medicine.
Dr. Barton did not speak to the media on June 20. It is unclear whether she will face criminal charges.
6. Nurses and family members started to complain about inappropriate use of heroin in the hospital as far back as 1991, but administrators did not listen to their concerns, and investigations that followed were largely ignored or limited in scope, according to the report.
"Many of those deaths would not have happened" if these complaints had been heard, Jeremy Hunt, the health secretary, said in Parliament, apologizing on behalf of the government.