Pharmacy bodies join together to support pharmacy sector to learn from failures of care at Gosport

The General Pharmaceutical Council, Royal Pharmaceutical Society and Association of Pharmacy Technicians in the UK have joined together to publish a reflection and learning resource to support everyone across the pharmacy to learn the lessons from the Gosport Independent Panel report.

The report, published in June 2018, found that at least 450 patients died having been inappropriately prescribed opioids between 1998 and 2000. This continued despite a number of the nursing staff having raised concerns about the care being provided. The report found no evidence that pharmacists in the hospital raised concerns.

To support further reflection and learning, the GPhC, RPS and APTUK are calling on pharmacists, pharmacy technicians and pharmacy owners in all sectors to share and discuss the presentation which:

  • Brings together the key pharmacy themes from the Gosport Independent Panel report
  • Looks at current pharmacy practice and how things have changed
  • Recaps on the expectations on pharmacy professionals (pharmacists and pharmacy technicians) and systems
  • Highlights key resources and other materials

The slides emphasise that pharmacy practice has improved significantly since these incidents took place, including through strengthened professional requirements, the introduction of the duty of candour, improved oversight of controlled drugs, and closer working across the multi-disciplinary team. It is important to reflect and learn from what happened to make sure that these failures in care are never repeated.

Ahead of the publication of the slides Nigel Clarke, Chair of the GPhC, said:

“The conclusions of the Gosport Independent Panel’s report are shocking, and we all need to make sure we learn from the devastating accounts of the families of patients who were failed by their health and care professionals, and by the wider system.  Pharmacy practice has now moved on significantly since the terrible events at Gosport took place; all professionals are expected now to speak out under the duty of candour when there are issues or things have gone wrong, and we underline the importance of learning and reflection.

“We would urge everyone across pharmacy to consider the presentation and discuss what this means for their practice with other professionals, students and support staff. Pharmacy professionals should also consider using this resource for their reflective accounts or peer discussions as part of revalidation. The lessons learnt from Gosport are very relevant to the three standards that all pharmacy professionals must reflect on in the coming year; communicating effectively, behaving professionally and demonstrating leadership.”

Ash Soni, President, Royal Pharmaceutical Society said:

“The lesson for everyone is to encourage and support a culture of patient safety in all care settings. We are pleased to have joined together with the GPhC and APTUK to develop this set of slides to support everyone across pharmacy to learn these lessons. We hosted an event in December which supported the development of these slides and our Hospital Expert Advisory Group, has also published a discussion paper with areas for action.”

Tess Fenn, Past President of APTUK said:

“Since the significant failures at Gosport Memorial Hospital, the role of the pharmacy technician has evolved exponentially. Pharmacy technicians are now an important component of front line pharmacy care and are often the first point of contact for patients and the public in both hospitals and community settings. As the role of the pharmacy team continues to expand, these slides should be used across all settings and will serve as a useful learning tool to ensure the harrowing events are never repeated.”  

Download a copy of the learning and reflective tool.