Thousands of elderly patients may have died prematurely because of cheap, faulty syringe pumps in a scandal described as “one of the biggest cover-ups” in NHS history, The Sunday Times reveals today.
A whistleblower on the government inquiry into hundreds of deaths at Gosport War Memorial Hospital, Hampshire, said decision makers on the panel had “ignored” evidence of fatalities caused by the devices because they feared a national scandal.
The pumps, or drivers, used in the NHS for at least 30 years, led to the rapid infusion of dangerous doses of drugs into the bloodstream and made the behaviour of Dr Jane Barton — in charge of prescribing medicine on the Gosport wards — even more dangerous than had been thought. She was found responsible last week for the deaths of up to 650 people and a culture in which powerful opiates were routinely and recklessly prescribed.
Because of ambiguous measurements and faults in the devices, it was easy to overlook mistakes in administering drugs, and they were dispensed much faster than nurses and doctors realised.
The Gosport inquiry was aware that detectives had interrogated Barton and other staff about the devices during Operation Rochester in 2003, when one doctor admitted they were “totally confusing” and “really dangerous”.
The admission is in 43,000 documents placed online when the inquiry reported last week. But the report, of 192,000 words, deals with the syringes in two sentences.
A Department of Health whistleblower says the question of the pumps was “buried” after senior members of the inquiry realised its implications for the NHS. Papers submitted on the topic were ignored in the final report. A Sunday Times investigation has found deaths linked to the devices continued until at least 2013.
The whistleblower said: “This could be one of the biggest cover- ups in NHS history. Anyone who has lost their granny over the past 30 years when opiates were administered by this equipment will be asking themselves, ‘Is that what killed Granny?’ ”
The panel was warned that a national helpline and a no-fault compensation fund would need to be set up if the full scandal emerged, the source added.
After Barton left Gosport in 2000, suspicious deaths occurred, albeit at a lower rate. More than 100 syringe drivers at the hospital trust were withdrawn just over a year after her departure, following a series of “critical incidents”.
Hampshire Police opened Operation Liffin in 2003 to investigate a fatal opiate injection linked to the devices at Gosport that year. Its outcome is unknown.
The devices were banned elsewhere, including New Zealand and Australia, but remained in use in the NHS. Called Graseby MS 16A MS 26 syringe drivers, they were loaded with capsules and programmed to release drugs into a patient’s bloodstream over an extended period so doctors and nurses did not have to inject manually. A 2008 NHS paper described the drivers as an “essential component of British palliative care” that had influenced end-of-life healthcare and policy across the UK.
An estimated 40,000 drivers were in circulation in the NHS, representing more than a quarter of all such devices globally. Research in 2001 showed 61% of UK and Irish palliative care units had the Graseby MS 26, and 55% used a Graseby MS 16A.
However, they were vulnerable to human error and tampering. Incident reports show that in some cases they released a day’s dose in an hour. This led the British medicine regulator to issue “hazardous product” and safety alerts on the drivers as early as 1995.
Inspectors at NHS Scotland found Graseby drivers were causing “serious overinfusion and fatality” in 1996. They were withdrawn in Australia and New Zealand in the mid-2000s after it was found they did not comply with even “minimum safety” standards. This newspaper has found that in the same decade Graseby devices were linked to overdose-related deaths in Wales, South Yorkshire, North Yorkshire, Derbyshire, Devon, Cornwall and the Isles of Scilly.
The NHS issued a notice recommending that hospitals replace Graseby drivers in 2010, but it fell short of a formal recall and deaths continued until at least 2013, according to NHS records.
The drivers remained in use until 2015, when a deadline to remove them, issued by an NHS body, the National Patient Safety Agency, expired. Production ended in 2014, although the maker, Smiths Group, still supplies parts and advice in some countries.
Britain was unique among developed countries in its reliance on diamorphine, the most potent painkiller and the pure form of heroin. In most other countries its use is discouraged or unlawful.
The Gosport inquiry found that more than half of Barton’s patients who received diamorphine were not even recorded as being in pain.
One in six deaths in Britain occurred after “continuous deep sedation” in 2007-8, according to researchers at Barts and the London School of Medicine and Dentistry, double the rate in Belgium and Holland.
When Hampshire detectives asked Barton about the devices in 2006 she replied: “No comment.” A colleague, Dr Richard Ian Reid, told police that having two similar-looking types of Graseby driver was “totally confusing” and led to errors. A police doctor joked: “We have similar problems with petrol and diesel.”
Charles Farthing, whose stepfather, Arthur (Brian) Cunningham, 78, was among the Gosport victims, said: “There needs to be a proper look at the use of these syringe drivers. They seemed to be hidden under pillows everywhere at the War Memorial Hospital.”
The Department of Health said: “In 2010 urgent guidelines were issued to the NHS on the use of these syringe drivers, advising the NHS to introduce safer equipment. The Gosport Independent Panel has highlighted the use of these devices between 1989 and 2000 in Gosport War Memorial Hospital which will be addressed as part of our response. We remain clear that we would also not hesitate to take further action to improve safety in the light of the report or other evidence as required.”
The Gosport panel said: “These allegations are completely unfounded and without merit or support.”