An inquest has found that at least 456 patients at Gosport War Memorial Hospital died after the unjustified administration of opioids under the watch of Dr Jane Barton.

The report released Wednesday found that there was an “institutionalised practice of the shortening of lives” and a “disregard for human life” at the Hampshire hospital where 456 patients died from 1989 to 2000, reports Sky News.

The four-year inquiry, which examined over one million pieces of evidence, also found that Hampshire Police, hospital management, the General Medical Council (GMC), the Nursing and Midwifery Council, and the Crown Prosecution Service (CPS) had “all failed to act in ways that would have better protected patients and relatives”.

There was an “institutionalised regime of prescribing and administering dangerous doses of a hazardous combination of medication not clinically indicated or justified, with patients and relatives powerless in their relationship with professional staff”, the Gosport Independent Panel investigation found.

An additional 200 patients were “probably” also killed by opiate painkillers when taking into account missing records, the report noted.

A source told The Times that the panel would not be pressing for a criminal investigation as “it is not in our remit.”

"There was an institutionalised practice of shortening lives" – Former Bishop of Liverpool James Jones is giving a statement after publishing a report on #Gosport War Memorial Hospital. Follow the latest here: https://t.co/y4GxR1a6GF pic.twitter.com/3hP86bfRS0 — Sky News (@SkyNews) June 20, 2018

Alarm bells were first raised in 1998 when the daughter of 91-year-old Gladys Richards reported to police concerns about Dr Barton’s opioid prescription after her mother died following recovery from a hip operation.

Police then launched an investigation into the deaths of 92 patients in 2002, and in 2006 the CPS decided that there was insufficient evidence to prosecute.

Dr Barton, described as “brusque and indifferent”, was found guilty of professional misconduct related to 12 patient deaths in 2010 by the GMC – but was not struck off the medical register and retired after the findings.

The panel found failings across the spectrum of medical professionals, as well, saying that though nurses administering the drug were not responsible for Dr Barton’s diamorphine prescriptions, they failed to challenge it. In addition, consultants who “were aware” of the opioid administration “did not intervene to stop the practice”.

#Gosport MP Caroline Dinenage asks why high numbers of deaths at the town's War Memorial Hospital were not properly investigated despite numerous #whistleblowers pic.twitter.com/xokhREbZtF — Sky News (@SkyNews) June 20, 2018

It was not until 2013 that the Baker Report found that opiate painkillers had likely “shortened the lives of some patients”. The review, by Richard Baker of the University of Leicester, was commissioned in 2003 but the department of health refused to publish it until a decade later, reports The Guardian.

Conservative MP for Gosport Caroline Dinenage highlighted the failures by authorities to investigate despite concerns being raised by relatives who have led this cause for two decades.

“The Crown Prosecution Service needs to look at it, Hampshire Constabulary need to look at it,” Ms. Dinenage said.

“I became an MP in 2010 and some of my constituents came to see me about it and at that point, there were inquests that still had not been completed. The Baker Report had been published in 2013 – it had been written in 2002. It’s taken all this time to get to the truth.”

In June, Breitbart London reported that Secretary of State for Health Jeremy Hunt will make it harder to strike off doctors who kill their patients, saying that he wants them to be allowed to “learn from their mistakes” and that “the NHS will support them to learn, rather than seek to blame”.

Britain’s NHS Lowers Standards, Doctors Who Kill Patients Will Keep Jobs and ‘Learn from Mistakes’ https://t.co/KwTx97Apb8 — Breitbart London (@BreitbartLondon) June 11, 2018