The damning findings of the £13m inquiry that took 4 years

The lives of 465 patients were shortened between 1987 and 2001 because they were given opioid drugs without medical justification.

It sought 2,024 patient records for the time period but could only find 1,564 complete enough to make clear conclusions.

A further 200 patients may have had their lives shortened, but their records are missing.

There was ‘a disregard for human life and a culture of shortening the lives of a large number of patients’.

Dr Jane Barton, the GP who worked as a clinical assistant at the hospital for 12 years and who was responsible for prescribing on the wards, routinely over prescribed drugs for her patients.

Nursing staff raised concerns about prescribing practice as far back as 1988, the year Barton began working at the hospital.

The number of deaths rose strikingly from 1989 – the year after Barton began working there.

There was an ‘equally striking decline’ over 1999 and 2000, with no instances in 2001. Barton left the hospital in 2000.

The practice of prescribing and administering drugs conflicted with national and local guidance that applied at the time.

The hospital’s use of diamorphine and midazolam reached a peak in 1998/99 and its use had become ‘excessive’.

There was an institutionalised regime of prescribing and administering ‘dangerous doses’ of a hazardous combination of medication not clinically justified, with patients and relatives powerless in dealings with staff.

When the relatives complained about the safety of patients and their care, they were consistently let down by those in authority.

Consultants were aware of Barton’s actions but did not intervene.

Some nurses did not challenge the prescribing of the drugs.

The senior management of the hospital, healthcare organisations, Hampshire Constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) all failed to act.

Previous investigations were hampered by medical experts not having access to the full range of medical records.

The three police investigations were ‘consistently poor’ and the officers’ mindset was ‘seeing the family members who complained as stirring up trouble’.