The inappropriate use of opioid drugs, which was at the heart of the Gosport War Memorial Hospital scandal in which at least 450 patients died between 1989 and 2000, could have been identified sooner if electronic prescribing had been in place, according to a report published by the Royal Pharmaceutical Society (RPS).
Prescribing patterns — including the inappropriate use of anticipatory prescribing — would have been “more visible to scrutiny” if electronic records had been kept, and an electronic record of medicine stock would have alerted a wider group of people to the drug abuses that were occurring, the report found.
The RPS said that changes in professional practice since the Gosport scandal mean pharmacists now work less in isolation and are more likely to be part of a multidisciplinary team, which would help prevent this scenario from happening again.
Governance around the use of opioids, such as the introduction of trust medicines safety officers and controlled drugs accountable officers, have also helped to improve patient safety, the report said.
“There are now more mechanisms in place [to] assure the safer use of opioids and a different culture around this,” the report noted.
It also called for trusts and pharmacy leaders to review existing drugs safety procedures, and said that work needed to be done to create a more open culture that challenges potentially unsafe prescribing or the unusual use of medicines. Concerns raised by family and carers should never be ignored, it stated.
The report also noted that rigorous up-to-date clinical audits are essential: “The most sobering lesson from Gosport is that the practice of anticipatory prescribing continued long after initial concerns were raised by nursing staff.”
“Patients and carers should expect pharmacy teams to provide information about medicines and to be their medicines safety advocates. If safety is compromised, pharmacists and their teams must have the confidence to speak up and challenge.”
The Gosport Independent Panel’s report, published in July 2018 after an independent inquiry, found no evidence that pharmacists or the Portsmouth Hospitals NHS Trust drugs and therapeutics committee had challenged prescribing practices.
It also expressed concern about how Gosport War Memorial Hospital adopted anticipatory prescribing practice and that it was used in cases where patients had been admitted for respite or rehabilitation — not just in palliative care.
The independent panel’s report also questioned the range of doses nurses were given the power to administer, and found that opioids were used without appropriate clinical need; that patients were started on “inappropriately high doses of opioids”; and that the opioids were combined with other drugs in “high” doses.