Bishop James Jones says Gosport hospital had institutionalised practice of shortening of lives
Documents used to investigate the deaths of Gosport War Memorial Hospital have revealed that 456 people died from the staff practice of prescribing too many painkillers.
Criminal charges could be brought following "truly shocking" revelations that the lives of more than 450 people had been shortened by the prescribing and administering of opioids without medical justification.
An additional 200 patients were "probably" similarly affected between 1989 and 2000.
The inquiry, led by the former bishop of Liverpool, the Rt Rev James Jones, did not ascribe criminal or civil liability for the deaths.
He said: "The documents show that between February 1991 and January 1992 a number of nurses raised concerns about the prescribing specifically of diamorphine. Their warnings went unheeded, the opportunity to rectify the practice was lost, deaths resulted and 22 years later it became necessary to establish the Panel in order to discover the truth of what happened."
Health Secretary Jeremy Hunt said the Gosport Independent Panel had identified a "catalogue of failings" by the authorities and apologised to the families who lost loved ones in the scandal.
He told MPs: "The police, working with the CPS and clinicians as necessary, will now carefully examine the new material in the report before determining their next steps and in particular whether criminal charges should now be brought."
He said any further investigations should be carried out by organisations not involved in previous probes, suggesting that Hampshire Constabulary should bring in another force.
The panel found that, over a 12-year period as clinical assistant, Dr Jane Barton was "responsible for the practice of prescribing which prevailed on the wards".
But Mr Hunt questioned whether there had been an "institutional desire" to blame the events on a "rogue doctor" to protect reputations rather than address systemic failings.
Mr Hunt said the report's findings were "truly shocking", with whistleblowers and families ignored as they attempted to raise concerns.
"There was a catalogue of failings by the local NHS, Hampshire Constabulary, the GMC, the NMC, the coroners and - as steward of the system - the Department of Health," he told MPs.
"Had the establishment listened when junior NHS staff spoke out, had the establishment listened when ordinary families raised concerns instead of treating them as troublemakers, many of those deaths would not have happened."
At Prime Minister's Questions, Theresa May said: "The events at Gosport Memorial Hospital were tragic, they are deeply troubling and they brought unimaginable heartache to the families concerned."
The Gosport Independent Panel found that hospital management, Hampshire Police, the Crown Prosecution Service (CPS), General Medical Council (GMC) and Nursing and Midwifery Council (NMC) "all failed to act in ways that would have better protected patients and relatives".
Its report also highlighted failings by healthcare organisations, local politicians and the coronial system.
The Gosport Independent Panel investigation into hundreds of suspicious deaths at the hospital, which was first launched in 2014, examined more than a million pages.
It revealed "there was a disregard for human life and a culture of shortening lives of a large number of patients" at the Hampshire hospital.
The report added: "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."
When relatives complained or raised concerns, they were "consistently let down by those in authority - both individuals and institutions".
The report concludes: "The panel found evidence of opioid use without appropriate clinical indication in 456 patients.
"The panel concludes that, taking into account missing records, there were probably at least another 200 patients similarly affected but whose clinical notes were not found.
"The panel's analysis therefore demonstrates that the lives of over 450 people were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital, and that probably at least another 200 patients were similarly affected."
In 2010, the GMC ruled that Dr Barton, who has since retired, was guilty of multiple instances of professional misconduct relating to 12 patients who died at the hospital.
Nurses on the ward were not responsible for the practice but did administer the drugs, including via syringe drivers, and failed to challenge prescribing, the panel said.
Consultants, though not directly involved in treating patients on the ward, "were aware" of how drugs were administered but "did not intervene to stop the practice".
Mr Hunt told the Commons that while the incidents "seemed to involve one doctor in particular" he questioned why consultants or nurses did not act to stop them.
He added: "Was there an institutional desire to blame the issues on one rogue doctor rather than examine systemic failings that prevented issues being picked up and dealt with quickly driven, as this report suggests it may have been, by a desire to protect organisational reputations?"
Hampshire Police chief constable Olivia Pinkney said: "Now that the report has been published and shared with us, we will take the time to read its findings carefully.
"We will assess any new information contained within the report in conjunction with our partners in health and the Crown Prosecution Service in order to decide the next steps."