Three out of 10 elderly patients who died at a hospital were given inappropriate medication, an inquest jury ruled today.
The panel of five women and three men spent four weeks at Portsmouth Coroner's Court looking at how the 10 died at the Gosport War Memorial Hospital in Hampshire more than 10 years ago.
They ruled that in the cases of Robert Wilson, Elsie Devine and Geoffrey Packman the medication was not appropriate for their condition and symptoms but had been given for therapeutic reasons.
They also ruled that medication had contributed to the death of Elsie Lavender and Arthur Cunningham (known as Brian) but had been given for therapeutic reasons and was appropriate for their condition.
The jury ruled that medication had not contributed to the deaths of the other five patients, who were Leslie Pittock, Helena Service, Ruby Lake, Enid Spurgin and Sheila Gregory.
The hearings had to be given special permission by Justice Secretary Jack Straw because seven of the bodies have since been cremated.
The inquest heard that each of the 10 patients went to the hospital for palliative care but died while at the community hospital.
The jury heard evidence from members of the patients' families, medical experts and staff at the hospital, including Dr Jane Barton.
She was the only individual to be investigated by police in connection with deaths at the hospital but she was not charged with any offence.
Hampshire Police carried out a series of investigations into the treatment of 92 patients at the Gosport War Memorial Hospital in the late 1990s but no action was taken.
The families of those who died believe that sedatives such as diamorphine were over-prescribed at the hospital and this led to the deaths of their relatives, who were receiving recuperative care.
But staff said that many of those who died were seriously ill.
The inquests were into the deaths of Arthur Cunningham, 79, from Gosport who died on 26 September 1998; Elsie Devine, 88, on 21 November 1999; Sheila Gregory, 91, of Gosport, on 22 November 1999 and Ruby Lake, 84, of Gosport, on 21 August 1998.
The other deaths are of Elsie Lavender, 83, of Gosport, on 6 March 1996; Geoffrey Packman, 67, of Emsworth, on 3 September 1999; Leslie Pittock, 82, on 24 January 1996; Helena Service, 99, of Gosport, on 5 June 1997; Enid Spurgin, 92, of Gosport, on 13 April 1999, and Robert Wilson, 74, of Sarisbury Green, on 18 October 1998.
Speaking outside the court in a press conference, the families of some of the patients called for the police investigation into deaths at the hospital to be reopened.
Bridget Reeves, granddaughter of Elsie Devine, along with her mother Ann Reeves and Ian Wilson also called for Dr Barton to be prosecuted.
She said in a statement: "The elderly and the public deserve better. If somebody is going to die, it is not up to the doctor to decide when that will be.
"It is their basic right to have their families around them in the last few days.
"A right which Jane Barton took from the families at will."
Following the inquest verdict, patient safety charity Action against Medical Accidents (AvMA) called for a public inquiry.
AvMA chief executive Peter Walsh said: "It is now quite clear the refusal to hold a public inquiry was wrong.
"The inquests have raised more questions than they have answered. It was impossible to do justice to all 10 deaths in one go.
"In any case, there were other deaths at Gosport which should have been looked into as well as the role played by various agencies, which may have prevented the poor practice at Gosport or it being investigated promptly and appropriately.
"There are lessons here for other health scandals, such as that at Stafford hospital. Only an independent public inquiry can get to the bottom of all the relevant issues."
AvMA is also calling for a review of the use of painkillers such as diamorphine and for legal aid to be made more widely available in cases such as these inquests.
Richard Samuel, director of performance and standards for NHS Hampshire which has inherited control of GWMH, said: "We have fully supported the coroner's inquests as a valuable opportunity to review the events of the late 1990s and we sympathise with the families for the uncertainty they have felt around the circumstances of their relatives' death.
"It is important for everyone involved in the care of these patients that five verdicts indicate that the medication used to treat and relieve their symptoms did not contribute to their deaths.
"In two verdicts, whilst contributing to death, medication was appropriately given.
"It is a matter of regret to the NHS that three verdicts indicate that in the mid/late 1990s the medication administered to these patients has been found to have contributed to their deaths.
"However, in those cases it was found to have been given for therapeutic purposes.
"NHS Hampshire will now be contacting these families but I would also like to take this opportunity to apologise to the families concerned on behalf of the NHS for any treatment or care which has been found to have contributed to the deaths of their loved ones.
"Since the late 1990s the systems and policies in place at Gosport War Memorial Hospital have undergone a complete overhaul.
"I can assure the families and local people that all the issues highlighted by these inquests have been addressed and the care at Gosport War Memorial Hospital today is of the highest standard."
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