More than 450 patients died after being given powerful painkillers inappropriately at a UK hospital, a report has found. A further 200 patients may have suffered a similar fate. An independent inquiry found there was an “institutionalised regime” of prescribing and administering dangerous amounts of morphine to elderly patients without clinical justification.

The practice was overseen by Dr Jane Barton and assisted by some of the nurses working at the hospital.

Established to address concerns about the deaths of the patients, the inquiry’s work included looking at 833 death certificates signed by Dr Barton who oversaw the practice of over-prescribing morphine on the wards in question. So far, the only person to face disciplinary action has been Dr Barton, who was found guilty of failings in her care of patients in her care at Gosport Hospital between 1996 and 1999. But no prosecutions were brought and she was not struck off the medical register, choosing to retire after the findings.

Bridget Reeves – whose grandmother Elsie Divine, 88, died at the hospital in 1999 – said: “These horrifying, shameful, unforgivable actions need to be disclosed in a criminal court for a jury to decide and only then can we put our loved ones to rest.”