Health and Social Care Management: Gosport Hospital Case Analysis

This report analyzes the impact of unethical business practices on healthcare organizations, focusing on the Gosport War Memorial Hospital case. The report details the tragic consequences of medical negligence, including the deaths of 456 patients due to the overprescription of opioid drugs. It evaluates the influence of inefficient organizational culture, and the lack of whistleblower protection, on the hospital's ability to prevent such incidents. The report provides recommendations for managing the repercussions of unethical conduct, emphasizing the need for ethical business operations. The case highlights the importance of ethical conduct, organizational culture, and regulatory oversight in the healthcare industry, and the severe impact of these factors on patient care and trust.

Running head: HEALTH AND SOCIAL CARE MANAGEMENT
Health and Social Care Management
Name of the Student
Name of the University
Author Note

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Executive Summary:
The paper discusses regarding the impact of the unethical business operations on the business
performances of the medical organizations. The paper portrays the impact of a horrendous act
of medical negligence that took place in Gosport War Memorial Hospital. While evaluating the
act, the paper provides significant information of the casualties of 456 number of patients. In
addition to this, the paper analyses the impact of the inefficient organizational culture and the
lack of security for the whistle blowers on the organization’s capability of avoiding such dreadful
cases. Depending on the findings of the case, the paper provides significantly important sets of
recommendations for the efficient management of the impact of the unethical business
conduction.

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Table of Contents
Introduction:...............................................................................................................................3
Overview of the Organization:...................................................................................................4
Case:...........................................................................................................................................4
Evaluation and Recommendations:............................................................................................6
Conclusion:................................................................................................................................8
References:...............................................................................................................................10

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Introduction:
The organizational culture in the modern business world, is observed to have
tremendous impact of the ethical business conduction of the modern business organizations.
The importance of establishing the corporate ethics in the business operations of the
organizations is seen to be of great significance (Herring 2014). With the impact of the
globalization, the level of the competition in the business industry is seen to increase in a
significant manner. Almost all the major industries and business sectors are seen to be
populated with the entry of the large number of new business organizations and that is one of
the key factor responsible for the significant level of competition that the existing companies
are facing in the business industry. With a precise focus on the intensity of the competition,
many of the traditional business organizations are seen to try the strategies such as the
product development or the low pricing policies for the products and the services that they
offer to their customers.
However, some of the organizations are observed to avoid the traditional strategies
such as price war and for them, the achievement of the preferences of the customers is pretty
easy through having a positive impact on their beliefs and the societal values. The practice of
the corporate ethics is considered to be most suitable strategy for those companies as that
have the potential to influence the purchase intentions of the customers in a significant
manner (Doshi and Jefferson 2013). However, many of the organizations are observed to
conduct unethical business operations in order to gain the competitive advantage over the
competitor organizations and under such situation, the reputational damage has the potential
to affect the business operations of those organizations in a notable manner (Percival 2014).
The paper describes one such case where it elaborates the unethical business operations of the
Gosport War Memorial Hospital. Along with that, the paper also presents the actions that the

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mentioned organization can undertake in order to minimize the detrimental impact of the
above mentioned event on the business operations of the selected organization.
Overview of the Organization:
Gosport War Memorial Hospital is one of the significant name in the health and social
care industry of United Kingdom. The chosen organization is established in the Gosport region of
Hampshire and is a major part of the Southern Health NHS Foundation Trust
(Southernhealth.nhs.uk. 2019). The selected organization was opened in the year 1923
(Southernhealth.nhs.uk. 2019). The hospital has a rich history associated with it and that is
pretty evident with the foundation of the selected hospital. The selected hospital was built in the
memory of the members of the Portsmouth Division of the Royal Marine Light Infantry who
expired during the First World War (Southernhealth.nhs.uk. 2019).
Later, in the year 1948, the selected hospital was included in the National Health Service
and that introduced a significant infrastructural development in the form of emergency
departments, physical medicine, the x-ray facilities along with the maternity ward (Nhs.uk.
2019).
Case:
The chosen case of the above mentioned hospital is a classic example of the impact of the
unethical business practices over the purchase intention of the customers of the organizations
along with the impact of inappropriate business operations on the reputation of the selected
organization. In the year 1990, a tragic incident took place when almost 456 number of patients
died and more than 200 number of patients had their lives shortened owing to the unnecessary
application of the opioid drugs (Boseley 2019). The Diamorphine is considered to be one of the
main life shortening opioid drug that has tremendous detrimental impact on the health and
survival of the people. Jane Barton, a clinical assistant of the selected hospital was found guilty

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of routinely overprescribing the opioid drugs for the patients in the year 1990 which killed 456
number of patients ad at the same time, it shortened the life of more than 200 number of patients
(Psnet.ahrq.gov. 2019). The impact of the incident was pretty significant ion the families of the
people. The families of the patients had continuously fought against the odds in proving the guilt
of Dr. Jane Barton who had worked for 12 long years for the selected hospital and the others
associated with the act through keeping it secret and claiming Dr. Barton to be innocent.
However, the consultants knew about the incident and the deeds of Dr. Barton. The nurses and
the pharmacists of the selected hospital administered the high level drugs in a frequent manner
and they had the knowledge of the fact that the injection of these sorts of drugs is not always
appropriate. Having said that, some of the senior nurses of the selected hospital wanted to blow
the whistle in the year 1991 over the inappropriate usage of the diamorphine which is the medical
name of heroin for the patients who were not in pain and along with that, they tried to raise their
concern of absence of adjustment of the doses in accordance to the patients’ needs. However,
the mentioned group of nurses were warned for not dragging the issue any further and to remain
silent over their concerns. Hence none of the nurses or the medical staffs of the selected
hospital raised the issue in the staff meeting that was attended by the convenor from the Royal
College of Nursing and that elaborates the fear of the medical staffs associated with the hospital.
Almost 19 long years later, in the year 2009, Dr. Barton was placed in front of a disciplinary
tribunal that was framed in Gosport War Memorial Hospital and was an eminent doctor’s
regulatory body (Gmc-uk.org. 2019). The disciplinary tribunal imposed considerable amount of
restrictions on the operations of the Dr. Barton. However, the managing authority of the selected
hospital later accepted the fact that they should not have allowed her to be associated with any
sort of medical operations. It is pretty evident that the Opioid drugs are used on recommendations
of the doctors in order to provide the much required relief from the severe pain ( Rudd et al.
2016). However, the medical reports collected from the selected hospital were insufficient, but
there was not proper justification for the injection of the opioid drugs. The collected reports

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partially presented a case where the injection of the opioid drugs was considered to be
“anticipatory prescribing”, however, that can only be used in providing relief to the patients from
the severe pain in case the patients need it. The collected records are pretty significant in stating
the fact that the “anticipatory prescribing” with a significantly high dose without any sort of
specific trigger for starting or ending.
With precise consideration on the claim of Pauline Spilka, a nurse of the selected
hospital, in front of the Hampshire police in the year 2001, it seems that they were convinced
regarding the injection of the opioid drugs to the patients who are evaluated to be on the
verge of dying. However, a proper evaluation of the records collected from the hospital
clarify the fact that in some cases, the “anticipatory prescribing” was conducted on the day of
the admission of the patients and even before getting admitted for the end-of-life-care.
Evaluation and Recommendations:
The case presented the impact of declining organizational culture and an environment
of fear over the business operations of the employees. It is visible from the case that the other
nurses or the medical staffs had the idea of the misconduct, however, they were threatened
not to communicate their concern to the convenor of the Royal College of Nursing (Rcn.org.uk
2019). This made the group of senior nurses vulnerable inside the hospital in avoiding such
horrendous event that snatched 456 lives. The incapability of a large section of the medical staffs
and the deliberate covering of incident from a section of the management of the hospital was
pretty significant in producing a substantial reputational damage to the selected organization. It is
understandable that the families of the patients believe the fact that their closed ones will get the
best quality treatment in the hospitals and will recover smoothly. However, the impact of such
dreadful act breaks the belief of the families of the patients from all parts and creates a
detrimental distrust (Jones and Kelly 2014). As the hospitality industry is pretty much service

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oriented industry, this had the potential of creating a significant concern in the mind of the
consumers before taking the treatment from the selected hospital.
On the other hand, the significantly inefficient organizational culture of the selected
hospital portrays the threat for the whistle blowers inside the organization. The whistle blowing
against the unethical conduct of Dr. Barton had the possibility of reducing the detrimental impact
of the event and could have also contributed to a lesser number of casualty. However, the fear
factor imposed by a section of the management of the hospital on the senior nurses of the hospital
was a major reason of their incapability in sharing their concern regarding the inappropriate
injection of the opioid drugs to the convenor.
Apart from this, the case is significant in portraying the lesser consideration of the
management of the hospital on the issue which was significantly evident with just mere
reduction in the operations of Dr. Barton as consequences for her misconduct. Though the
selected organization later realized the importance of talking her out of the actions or her
usual operations, it was pretty late for them as they missed the opportunity to create a strong
image amongst the customers which could have increased the preferences of the customers
towards the hospital and could have recovered the reputational damage that they faced as a
result of the event (Bonney 2014). Hence the case had the possibility of providing significant
amount of distress and disbelief amongst the customers regarding the business operations of
the selected hospital.
Apart from all these, one of the crucial part of the case was the apathy of the
regulatory bodies in evaluating these sorts of cases. The tenure of the case is pretty significant
in stating the reluctance of the police and the responsible regulatory authorities in evaluating
the case. Throughout the 20 or more years, the families of these patients have undergone an
experiences such as hell. None of the policemen or the officers of the regulatory bodies have
believed their claim and the members of the families of these patients were prohibited from

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getting the actual report of the incident from the part of the selected hospital which could
have made their life easier in convincing the society\. With a precise focus on this, it is
evident that majority of such cases do not appear in front of the higher authority owing to
significant extent of harassments that the families or the friends of the patients had to face
(Jones and Kelly 2014). Hence, under such situation the cases of unethical business
conduction such as this, continue to repeat and provide significant damage to the reputation
of the hospital.
The recommendations for the case will be to provide the much required safety and
security to the whistle blowers in the organizational context. This will be significant for the
senior management of the organization in reducing the impact of such unethical business
conduction inside the organization.
Along with that, the higher authority of the hospital needs to be strict in proper
implementation of the code of ethics which has the potential of making sure that the business
operations of the employees inside the hospital are in effectively alignment with the corporate
ethics.
Apart from this, the police and the regulatory bodies are advised to increase their
urgency in evaluating such dreadful cases. This will make sure that the culprits are caught
with improved efficiency and it eliminates the threats of unethical business operations from
the part of the employees of the organization.
Apart from this, the organization is expected to conduct the integrated marketing
communications for the effective management of the detrimental impact of the event and
communicate to the customers regarding the precautionary activities that they have
undertaken in order to maintain the values of their business.

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Conclusion:
On a concluding note, the case is pretty significant in establishing the detrimental
impact of the ineffective organizational culture. The organization had faced considerable
amount of reputational damage as a result of the event which not only affected their business
operations but also provided a major setback to the customers of the hospital. Apart from this,
the case is pretty significant in stating the impact of the negligence of the medical staffs and
the amount of suffering that the families of the patients had to experience in not only losing
their closed ones but also in convincing the case to the police and the regulatory authorities.
However the detrimental impact of these sort of events can be managed in an efficient
manner with the incorporation of the corporate ethics.

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References:
Bonney, W., 2014. Medical errors: Moral and ethical considerations. Journal of Hospital
Administration, 3(2), pp.80-88.
Boseley, S. 2019. Gosport hospital: more than 450 patients died due to opioid drugs policy.
[online] the Guardian. Available at:
https://www.theguardian.com/society/2018/jun/20/gosport-war-memorial-hospital-opioid-
drugs-policy-inquiry
Doshi, P. and Jefferson, T., 2013. Clinical study reports of randomised controlled trials: an
exploratory review of previously confidential industry reports. BmJ open, 3(2), p.e002496.
Gmc-uk.org. 2019. [online] Available at:
https://www.gmc-uk.org/-/media/documents/gosport-war-memorial-hospital-report-
gmcresponse_pdf-76338897.pdf
Herring, J., 2014. Medical law and ethics. Oxford University Press, USA.
Jones, A. and Kelly, D., 2014. Whistle‐blowing and workplace culture in older peoples' care:
qualitative insights from the healthcare and social care workforce. Sociology of health &
illness, 36(7), pp.986-1002.
Nhs.uk. 2019. Home. [online] Available at: https://www.nhs.uk/
Percival, T., 2014. Medical ethics. Cambridge University Press.
Psnet.ahrq.gov. 2019. Gosport War Memorial Hospital. The Report of the Gosport
Independent Panel. | AHRQ Patient Safety Network. [online] Available at:
https://psnet.ahrq.gov/resources/resource/32580/Gosport-War-Memorial-Hospital-The-
Report-of-the-Gosport-Independent-Panel

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Rcn.org.uk 2019. The Royal College of Nursing. RCN - Home | Royal College of Nursing.
[online] Available at: https://www.rcn.org.uk/
Rudd, R.A., Aleshire, N., Zibbell, J.E. and Matthew Gladden, R., 2016. Increases in drug and
opioid overdose deaths—United States, 2000–2014. American Journal of Transplantation,
16(4), pp.1323-1327.
Southernhealth.nhs.uk. 2019. Care to join us | your career starts here. [online] Available at:
https://www.southernhealth.nhs.uk/about/work-for-us/