Gosport inquiry - LIVE: Doctor 'responsible' for use of lethal levels of opiates which killed at least 450, inquiry finds

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Gosport hospital deaths: Norman Lamb accuses the NHS of closing ranks after deaths of elderly patients from alleged overprescribed painkiller drugs

Up to 650 patients died from lethal doses of opiate painkillers given “without medical justification” over a 12 year period at the Gosport War Memorial Hospital in Hampshire, a major public inquiry has found.

The Gosport Independent Panel found evidence of opioid use without an appropriate clinical justification in 456 of the patients who died, but taking into account the missing records it concludes there are “probably at least another 200 patients were similarly affected”.

Campaigners have called for prosecutions to follow the publication of the findings.

Later on Wednesday the government will give a statement on future prosecutions for the deaths after the report said the “institutionalised practice of shortening lives” between 1989 and 2000 was introduced by Dr Jane Barton.

The inquiry was led by the former bishop of Liverpool, the Rt Rev James Jones, who previously chaired the Hillsborough Independent Panel.

“The documents seen by the Panel show that for a 12 year period a clinical assistant, Dr Barton, was responsible for the practice of prescribing which prevailed on the wards,” the inquiry chair Bishop of Liverpool James Jones said.

A separate review into deaths at the hospital, led by Professor Richard Baker, found "almost routine use of opiates" for elderly patients had "almost certainly shortened the lives of some".

That report could not be published in full until 2013, 10 years after it was completed, while inquests were held and due to a police investigation.

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In 2010, the General Medical Council ruled that Dr Jane Barton, who has since retired, was guilty of multiple instances of professional misconduct relating to 12 patients who died at the hospital.

Health secretary Jeremy Hunt is due to address MPs on the findings of the Gosport inquiry, and will face questions about the previous investigations and whether charges should now be brought.

Cindy Grant's father, Stanley Carby, died at the hospital in 1999 after being admitted for rehabilitation following a stroke.

She said: "I think there is somebody that needs to be prosecuted for what's gone on there."

She told BBC Radio 4's Today programme: "We want justice to be served because these families' lives were taken - mums, dads, grandads, grandmas.

"We all know what went on at that hospital. We want justice served."

Liberal Democrat MP Stephen Lloyd, whose constituent, Gillian McKenzie, was the first to go to Hampshire Police in 1998 with concerns over the death of her mother, said lives might have been saved if she had been taken more seriously.

"If the police had taken her seriously, if the senior managers at the hospital had taken her seriously earlier, bluntly it appears that lives would have been saved.

"That is a shocking, shocking indictment of this entire process."

Mr Lloyd criticised the investigations carried out by the police and NHS, adding: "We finish finally with the GMC many years later finding that Dr Barton did overuse opiates and they didn't even debar her."

"I think it has been an absolute travesty for 20 years," he told Today.

The Eastbourne MP said: "If the report is as strong as I - and I think the relatives - anticipate, then I will be quizzing Jeremy Hunt directly and I will be saying to him that certain individuals should be facing criminal prosecution."

Key Points

• GP 'responsible' for practice of lethal opiate prescribing which killed at least 450 patients​
• Full statement from bishop James Jones, who led inquiry
• Health secretary Jeremy Hunt gives a statement to parliament

[20 June 2018 10:21 · Adam Withnall]

Hello and welcome to The Independent's live coverage of today's publication of findings by a public inquiry into suspicious deaths at Gosport War Memorial Hospital.

We'll bring you all the latest news as we have it, with conclusions by the Gosport Independent Panel set to be made public around 11.45am this morning.

[20 June 2018 10:37 · Adam Withnall]

Alex Matthews-King, The Independent's health correspondent, who is in Gosport for the publication of the panel's findings, has provided an in-depth look at fall-out from the scandal. 

[20 June 2018 10:58 · Adam Withnall]

Government officials tried to dodge inquiry into 800 deaths at single hospital, ex-health minister claims 

[20 June 2018 11:01 · Adam Withnall]

Families of those who died lay down signs outside Portsmouth Cathedral demanding "justice" for their relatives. 

[20 June 2018 11:38 · Adam Withnall]

The former Bishop of Liverpool, who headed the inquiry, is to provide a statement outside Portsmouth Cathedral any minute now. That will soon be followed by the release of documents they've used in the inquiry, before the issue is addressed at PMQs.

[20 June 2018 11:46 · Adam Withnall]

 

[20 June 2018 11:48 · Adam Withnall]

Bishop James Jones says hospital staff, healthcare organisations, police, politicians and the GMC "all failed to act in ways that would have better protected patients and relatives" in a statement outside Portsmouth Cathedral.

[20 June 2018 11:49 · Adam Withnall]

An "institutionalised regime" of prescribing and administering opioids without medical justification at the Gosport War Memorial Hospital shortened the lives of more than 450 people, an inquiry has found.

An additional 200 patients were "probably" similarly affected between 1989 and 2000, when taking into account missing records, according to a report by the Gosport Independent Panel.

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", the panel said.

Its report also highlighted failings by healthcare organisations, local politicians and the coronial system.

[20 June 2018 11:55 · Adam Withnall]

The Gosport Independent Panel investigation, first launched in 2014, examined more than one million documents.

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."

[20 June 2018 12:15 · Adam Withnall]

Here is the full text of Bishop James Jones's statement on the publication of the report of the Gosport Independent Panel:

- Institutionalised practice of the shortening of lives

The documents reveal at Gosport War Memorial Hospital from 1989 to 2000 an institutionalised practice of the shortening of lives through prescribing and administering opioids without medical justification.

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.

- The numbers

The hospital records to which the Panel has had privileged access demonstrate that 456 patients died through prescribing and administering opioids without medical justification.

The Panel concludes that taking into account missing records there were probably at least another 200 patients whose lives were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital.

The pattern of opioid use without appropriate clinical indication followed a clear pattern over time. The Panel found no instances in 1987 or 1988 but the numbers rose markedly followed by an equally striking decline over 1999 and 2000, with no instances in 2001.

- Not for the Panel to ascribe criminal of civil liability

It is not for the Panel to ascribe criminal or civil liability. It will be for any future judicial processes to determine whatever culpability and criticism might be forthcoming.

The documents seen by the Panel show that for a 12-year period a clinical assistant, Dr Barton was responsible for the practice of prescribing which prevailed on the wards. Although the consultants were not involved directly in treating patients on the wards, the medical records show that they were not aware of how drugs were prescribed and administered but did not intervene to stop the practice.

Nurses had a responsibility to challenge prescribing where it was not in the interests of the patient. The records show that the nurses did not discharge that responsibility and continued to administer the drugs prescribed.

The documents also demonstrate the suboptimal care and lack of diligence by nursing staff in executing their professional accountability for the care delivered. Patients and relatives were marginalised by the professional staff.

- How could the practice continue and not be stopped through police regulatory and inquests processes

Families will ask, how could this practice continue and not be stopped through the various police, regulatory and inquest processes. The Panel's report shows how those processes of scrutiny unfolded and how the families were failed.

Respective chapters of the report show how the relevant healthcare organisations failed to recognise what was happening at the hospital and failed to act to put it right; how the police investigations were limited in their depth and in the range of possible offences pursued; how the process of the General Medical Council and the Nursing and Midwifery Council were delayed; and how the inquests proceeded.

The documents show how the media coverage played a significant part in encouraging staff who had worked on the wards to take action. And how Sir Peter Viggers, as the local MP, questioned the need for repeated inquiries into had happened at the hospital.

- Families in their tenacity and fortitude

Throughout, the relatives have shown remarkable tenacity and fortitude in questioning what happened to their loved ones. The documents explained and published today show that they were right to ask those questions. The families deserve every support in absorbing what is revealed ad whatever future processes now follow.

- Completion of the Panel's terms of reference

The Panel has listened to the families and the documents now highlighted in its report reveal what those documents add to public understanding.

The Panel now calls upon the Secretary of State for Health and Social Care, the Home Secretary, Attorney General and the Chief Constable of Hampshire Police and the relevant investigative authorities to recognise the significance of what is revealed about the circumstances of deaths at the hospital and to act accordingly.

Alongside its report, the panel has published an online archive of documentation. The panel is aware that some documents include personal opinions of individuals and statements about individuals, where those concerned have not had the opportunity to respond to comments or criticism. In reading the disclosed documents it is important to be sensitive to this situation.