TIMELINE OF TRAGIC FAILINGS

1988 Dr Jane Barton starts working at Gosport War Memorial Hospital. Hip operation patient Gladys Richards dies that August. 1991/92

Staff raise concerns about increased mortality rate, ‘unnecessary’ use of diamorphine and concerns about Dr Barton’s administration of diamorphine. 1998 Hampshire Police’s first investigation into deaths after Gladys Richards case. Her two daughters call the force to allege she was unlawfully killed. 1999 Police submit papers to the CPS, but CPS decides no prosecution would be justified. Three more families complain. 2000 NHS Independent Review Panel finds that, while drug doses were high, they were appropriate. Hampshire Police

reopen Mrs Richards’ case. Experts find her ‘death occurred earlier than it would have done from natural causes’ but CPS says again there is insufficient evidence. 2001

More families raise concerns and four selected for review. Two experts give conflicting opinions, but police do not forward these to CPS. Commission for Health Improvement begins investigation into care and management, interviewing 59 staff.

2002

CHI report faults the hospital’s systems to provide good care. Professor Richard Baker commissioned to analyse mortality rates. Hampshire Police open third inquiry after relatives of 62 patients contact force. 92 deaths probed, 78 fail to meet ‘negligence’ threshold. In four more ‘essential element of causation could never be proven’. 2003 Baker report finishes but not made

public. Finds almost routine use of opiates which almost certainly shortened some lives.

2006 Police investigation narrows to ten deaths. A ‘common denominator’ is that Dr Barton was responsible for care of cases. She is interviewed. CPS decides it cannot ‘be proved that doctors were negligent to criminal standard’. 2009 Inquests into the ten deaths investigated by police. Narrative verdicts say five patients given medication not appropriate and contributed to deaths. It is also ruled medication had contributed to two more deaths but had been given for therapeutic reasons. Medication had not contributed to the other five deaths.

2010 GMC finds Dr Barton guilty of misconduct and that she prescribed ‘potentially hazardous’ levels of drugs. She is not struck off but given a list of 11 conditions relating to her practice. She retires. CPS says no criminal charges are to be brought against her after finding insufficient evidence to prosecute for gross negligence manslaughter in ten cases. Ann Reeves, daughter of patient Elsie Devine, leads a protest march to Downing Street.

2013 Final and eleventh inquest into Gladys Richards finds painkillers and sedatives ‘more than insignificantly’ contributed to her death. Baker report published, ten years after it concluded. 2014 Health minister Norman Lamb establishes inquiry which released its report yesterday.