Seventy years after a leaflet dropped on the doormat of every household informing them of a new entitlement to free healthcare, the NHS remains our most cherished national institution. But as the country stands poised to celebrate its birthday, the independent review of patient deaths at Gosport War Memorial hospital is a tragic reminder of just how difficult it can be for relatives to get to the truth when things go badly wrong for the people who the NHS cares for.

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The review found that between 1988 and 2000, at least 450 patients at the hospital had their lives shortened as a result of being prescribed powerful opioids without medical justification. Some were expecting to stay for just a few weeks’ rehabilitation before returning home. The report’s sickening conclusion is that there was “a disregard for human life” at the hospital.

Much of the focus has been on why Jane Barton, the doctor chiefly responsible, has faced so few consequences. It was more than 10 years after the first complaint was made – and more than five years after an audit for the Department of Health raised serious concerns – for her to be investigated by the General Medical Council. The GMC panel found her guilty of serious professional misconduct and expressed concern about her refusal to admit she was wrong but did not strike her off.

Yet the independent panel is clear that it was not just a single doctor who failed these patients. A group of nurses raised concerns as long ago as 1988, but was silenced by managers. Consultants were aware of the way in which these drugs were being administered, but did not intervene. None has faced disciplinary action. And relatives’ 21-year fight for answers represents the monumental failure of a system. The report documents how they were repeatedly let down over the years: by professional regulators, by the police, by the Crown Prosecution Service and by their former local MP. Had their concerns been taken seriously from the beginning, hundreds of lives could have been lengthened. Instead, the appalling levels of care were allowed to persist for more than a decade.

Call to hold officials to account for Gosport deaths 'cover-up' Read more

There will inevitably be variability in the quality of care in every healthcare system. What matters most is that unsafe or negligent care is immediately identified and addressed. But the findings of the Gosport report echo those of recent reviews into failures at Mid Staffs and Morecambe Bay. Too often in recent NHS history, appalling care has gone hand in hand with a complete unwillingness to listen to, and take action over, serious complaints. Thousands of lives have been lost as a result.

In response to these inquiries, the government has introduced a “duty of candour” for medical professionals to be open and honest with patients when things go wrong. It has also improved protections for whistleblowers and is in the process of establishing a new investigation body for the NHS in England to investigate suspicious deaths.

There are questions about whether these measures go far enough. But by far the biggest caveat is that the government’s underfunding of the NHS and social care since 2010 has itself undermined patient safety: the understaffed wards, cancelled operations and stretched resources that have resulted make unsafe care more likely to happen. Last week’s announcement of extra funding will go some way towards closing the gap, but experts say it still falls short of what’s needed to put the NHS on a sustainable footing in the context of an ageing population.

When someone dies as a result of appalling, unsafe care, the very least their relatives should be able to expect is a heartfelt apology and an assurance that it will never be allowed to happen again. Instead, the families of those who died in Gosport War Memorial hospital – like the families of those who died at Mid Staffs and Morecambe Bay – have had to fight for decades for the truth and witness others going through the same, preventable ordeal. It must not be allowed to happen again.