45 Archeological dig: a historical review of local evidence, guidelines and clinical practice in response to the gosport enquiry

Abstract

Background The Gosport Report suggests over 450 patients died due to ‘dangerous doses’ of medication combinations without clinical indication. A cross-boundary integrated specialist palliative care service reviewed factors influencing prescribing culture for patients approaching end-of-life. Methods A historical review of pain management and syringe driver use was considered alongside locality guidelines. Training programmes were reviewed and meetings held with stakeholders. Audits were undertaken to seek assurance of safe local prescribing practices. Results During the Gosport period, there was clear guidance available for safe opioid starting doses, dose equivalences & syringe driver use. Medical Devices Alerts regarding the risks of multiple syringe driver devices in use, led to use of a single device across locality. Local guidelines have always stated no indication for ‘anticipatory prescribing for medication via a syringe driver’. Multi-professional education has evolved & adapted over time to reflect key national guidelines & staff training needs. Review of all hospital deaths during April 2018 showed less than 30% received a continuous subcutaneous infusion of medication prior to death. Clinical indication was clearly documented & mean starting doses were small (Diamorphine 6 mg, midazolam 7.5 mg). There was no evidence of anticipatory prescribing of syringe drivers, or the prescribing of dose ranges in hospital. Conclusion A review of end-of-life prescribing prompted by the Gosport Report gives assurance that prescribing practices described, are not seen locally. A culture promoting safe end-of-life prescribing has been fostered through readily available, evidence-based guidelines, safe procedures for syringe driver use, wide-reaching multi-professional education co-ordinated by the hospice education centre and an active end-of-life audit group. Strong clinical leadership gives a co-ordinated approach to promoting excellent end-of-life care.