Deadliest cover-up
Establishment ignored string of warnings over 3 decades
‘Should have known’
The report into the Gosport scandal laid bare 25 years of failings by the medical and legal establishment that it said entitled families to question whether there had been a cover-up.
Families were dismissed as troublemakers and were let down by health chiefs, police, medical bodies, coroners and ultimately the Department of health.
The 387-page report yesterday revealed that nurses raised concerns over Dr Jane Barton and the use of opiates at Gosport Memorial hospital back in 1988. Yet incredibly it has taken 30 years and a string of bungled investigations for the families of those who died at the hospital to get some semblance of justice.
Separate investigations by a number of authorities had all failed to lead to any criminal prosecutions.
Although the deaths were largely attributed to the actions of Barton, the report said other doctors and nurses should have known something was amiss. And it said that when whistleblowing staff or relatives did try to raise concerns, they were quickly slapped down by officials.
The report – by the former bishop of Liverpool James Jones – even said relatives were entitled to ask whether the failures amounted to a conspiracy.
It said: ‘The families, and indeed the nation as a whole, are entitled to ask how these events could have happened; how the hospital dismissed the nurses’ concerns and subsequently took no action; how the healthcare organisations failed to intervene; how the professional regulators allowed matters to continue; how the police failed to get to the bottom of what had happened; and whether what happened is to be explained as a conspiracy or in some other way.’
In the Commons, health Secretary Jeremy hunt admitted that deaths could have been prevented. he told MPs: ‘had the establishment listened when junior NHS staff spoke out, had the establishment listened when ordinary families raised concerns instead of treating them as troublemakers, many of those deaths would not have happened.’
he said there appeared to have been an ‘institutional desire’ among public officials throughout the scandal to ‘protect organisational reputations’.
In 1991, another nurse, Anita Tubbritt, raised her fears with a union representative and a meeting was arranged with staff and Barton. But she and worried colleagues were silenced by the hospital’s patient care manager Isobel evans as being ‘only a small group of night staff who are making waves’.
had she taken them seriously, hundreds of deaths could have been prevented.
The report also drew attention to the fact that many other nurses failed to intervene even though they must have known something was wrong.
Up to ten consultants who specialised in caring for the elderly were meant to be supervising Barton as well.
Although she saw patients for two hours each morning, these senior doctors should have been checking the medicines she was prescribing and the doses.
The report specifically named doctors Althea Lord, Jane Tandy, Richard Reid, David Jarrett and Bob Logan. It stated: ‘Although the consultants were not involved directly in treating patients on the wards, the medical records highlighted in this chapter show that they were aware of how drugs were prescribed and administered but did not intervene to stop the practice.’
None of these doctors were investigated by their professional medical body, the General Medical Council. Despite the level of concern over Barton’s behaviour, the GMC took ten years to disci- pline her. The council warned about her prescribing habits all the way back in July 2000 but it was not until January 2010 that she was found guilty of serious professional misconduct.
Astonishingly, the GMC did not strike her off but instead imposed sanctions that stated she had to be closely supervised and could not prescribe opiates.
She chose to retire two months later in March 2010 – on a generous GP pension. One of the reasons the GMC took so long was that it was awaiting evidence from hampshire Constabulary.
The report pointed out that the delay may well have worked in Barton’s favour because over those ten years she was able to claim she had a decade of ‘good practice.’ This may partly be why she was not struck off.
While the medical establishment’s failures were clear, hampshire Constabulary also came in for criticism yesterday.
The force carried out three investigations into patient deaths at the Gosport hospital between 1998 and 2010 but not enough evidence was found for Barton to be prosecuted. In some cases, the force did not take crucial statements from relatives, find witnesses or look for forensic evidence.
In conclusion, the inquiry found multiple organisations had ‘failed to identify the nature of the underlying problem’ or deal with it.
‘The documents show that following a complaint to the trust in 1998 and the police investigation, it should have become clear to local NHS organisations that there was a serious problem with services at the hospital,’ it said.
‘Although the successive police investigations undoubtedly complicated the NHS response, it is nevertheless remarkable that at no stage was there a public admission of failure or any public apology.
‘Nor was there proportionate clinical investigation into what had happened.
‘On the contrary, the documents show numerous instances of defensiveness and denial – to families, to the public and the media, and to health service and other organisations.’