Nursing staff first raised concerns about the poor prescribing and administration of opioids at the Gosport Memorial Hospital nearly 30 years ago but their fears were "silenced" by management, the inquiry reveals.
Early in 1991, Anita Tubbritt, a staff nurse at the hospital rang Keith Murray, the local Royal College of Nursing branch convener, to express concerns she and other staff shared over the use of diamorphine and syringe drivers.
Mr Murray had a meeting at the home of staff nurse Sylvia Giffin with five or six other nurses who said diamorphine "was being prescribed without due consideration being given to the use of milder sedatives first".
He said the nurses named Dr Jane Barton, a clinical assistant who attended the annexe daily, and Dr Bob Logan, a consultant geriatrician, who visited on certain days.
Mrs Giffin wrote to patient care manager Isobel Evans and she replied suggesting a meeting "so that a plan of action can be determined, if necessary".
Four days after the meeting, Mr Murray wrote to Mrs Evans and provided an open letter designed to encourage staff to talk freely at the proposed staff meeting.
That meeting was held in July and 10 nurses attended, raising concerns about the use of diamorphine and that "patients' deaths are sometimes hastened unnecessarily".
By October 1991 there had a been a "sharp shift in tone towards the nurses" from Mrs Evans, who had moved from "open and interested, to critical and patronising", the report stated.
Mr Murray, the RCN representative, again wrote to Mrs Evans saying the earlier agreement for a written policy governing the use of syringe drivers and controlled drugs had not been met.
He also wrote to Mrs Giffin advising that using the hospital grievance procedure may be the only way of resolving it.
Mr Murray also said how much he admired the staff involved "for standing up for your patients in the way that you are", the report said.
In December he wrote to Chris West, the district general manager at the Portsmouth and South East Hampshire Health Authority, saying the concerns of the nurses had been dismissed as "only a small group of night staff who are 'making waves'."
A meeting was held on December 17 for all staff members concerned about the prescribing of diamorphine, which was attended several doctors, including Dr Barton.
The note of the meeting shows that discussion was led by Mrs Evans, who said the issue "had put a great deal of stress on everyone particularly the medical staff, it has the potential of being detrimental to patient care and relatives'
peace of mind and could undermine the good work being done in the unit if allowed to get out of hand".
The notes of the meeting stated the nurses were asked whether there was any need for a written policy and no one present felt that this was appropriate.
"Mrs Evans went on to say that she was concerned 'over the manner in which these concerns had been raised as it had made people feel very threatened and defensive and stressed the need to present concerns in the agreed manner in future'," the notes revealed.
The report stated: "It appears that the meeting on December 17 had the effect of silencing the nurses' concerns, as well as closing down the question of the written policy.
"The documents reviewed by the Panel show that, between February 1991 and January 1992, 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 convener, 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."
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