Today's report has shed a light on what happened at Gosport Memorial War Hospital – the question now is why it happened

Damning and detailed as the report of the independent panel into the scandal at Gosport War Memorial Hospital is, it is only the beginning of the search for justice for the families, and to try again, depressingly, to ensure that such events will not happen again. It was, in the panel’s words, nothing less than the “institutionalised practice of shortening of lives through wrong use of opioids”.

What is clear, even at this point, is that 456 people died unnecessarily from excessive doses of opioids, and a further 200 or more may have suffered a similar fate, but whose records are missing or too incomplete to say. The panel looked at the period from 1988 to 2000, though the abuses may have gone on even longer.

On any reading it is an appalling toll. Typically an older patient would have been admitted to the hospital for some rehabilitation and reablement for a few weeks, but would be given such a quantity of diamorphine and other drugs that they would be dead within a couple of days.

The documentary evidence shows that clinical assistants did not check what was going on, that nurses knew the consequences of the doses being prescribed, that pharmacists did not question what was happening, and that when questions and complaints were raised they were not heeded or acted upon.

It need not, in other words, have been this way. Nurses as early as 1991 voiced disquiet to hospital management. A report by Professor Richard Baker prepared in 2003 was, in effect, buried by NHS lawyers on the grounds that it would prejudice other investigations. It was not released until 2013. It is difficult to believe that the rules of the system conspired to risk lives.

As the Right Reverend James Jones, chair of the panel, warned, the independent panel was not empowered to interrogate any witnesses during their work, nor, in fairness, to put allegations to the medical staff and others involved. It cannot lay blame or make final judgements.

What the panel did do was to dedicate themselves to collating as much evidence as they could find in the medical records and documents, and to piece together a story that is even more astounding than anyone feared.

A former bishop of Liverpool, Rev Jones, also chaired the independent panel on the Hillsborough tragedy; this is a further remarkable act of public service on his part. He has left it for others to take that work forward.

Now is the time, as the health secretary Jeremy Hunt and the Crown Prosecution Service have indicated, for more serious inquires to be pursued, and a case too for a public inquiry, under the 2005 act. In what order those further investigations take place will, as ever, be difficult to manage, but the aim should unequivocally be to secure justice for the families and make those responsible accountable and to have those culpable punished as soon as possible.

Such inquiries will need to be extensive. The panel, in its report, could not be plainer about how far the scandal spread: “The senior management of the hospital, healthcare organisations, Hampshire Constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and the Nursing and Midwifery Council all failed to act in ways that would have better protected patients and relatives, whose interests some subordinated to the reputation of the hospital and the professions involved. In the relationship with these powerful public bodies, the families have felt powerless.”

It was a peculiarly cruel form of medical abuse of power. Patients and families were given to understand, sincerely, by their doctors that the purpose of being sent to this hospital was for respite or rehabilitation. Instead, and incomprehensibly – the biggest question of all is why – they were set on a terminal care pathway. It was the taking of life, but aggravated by a terrible deception. That is grave enough. What also needs to be thoroughly investigated, and learned from, is why, after the Shipman case, such a state of affairs could persist for decades.

There is no doubt now when relatives objected they were consistently let down by those in authority – both individuals and institutions. There would seem to be a culture of misplaced faith in the integrity and professionalism of those responsible for clinical “care”.

In fact, the report shows that one decisive factor in discovering this abuse was the role of the local and national media. It is not self-interested for the media to underline this finding from the independent panel, and that it makes as strong case for the strengthening of the local and regional press in particular.

In the Gosport War Memorial Hospital case, the families often had nowhere else to turn. Without the interest of reporters and editors they might still be waiting for action, even after 20 years.