Medicines safety

Learning from the Gosport enquiry

The Gosport enquiry reported on poor prescribing practice at the Gosport War Memorial Hospital from 1987 to 2001. Although practices have changed substantially since 2001, there are still significant areas of learning, as reported by the Department of Health and the Faculty of Pain Medicine.

Key areas of poor practice were identified, including using anticipatory opioids without pain, wide dose ranges such as 20-200mg diamorphine infusion, and high doses for opioid naïve patients. In addition, failure to employ the analgesic ladder and management downplaying staff concerns were also identified as poor practice.

Pharmacists are recommended to become familiar with the Opioids Aware resource. The principles for medicines optimisation of opioid use in chronic non-malignant pain include:

  • Oral morphine as the drug of choice, little evidence of differences in effectiveness and side-effects using other drugs
  • Trial with pain scoring and defined outcomes (for example, for one to two weeks of constant pain)
  • Review doses and drug choice in renal impairment
  • Ensure naloxone is prescribed appropriately and investigated if administered.

Short term opioid use post-surgery or trauma is usually only needed at hospital discharge, and patients should be told how to taper doses during recovery.

We must all be open and honest, and support patients, families and staff to enable them to raise concerns.


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