Failures and cover-ups in Gosport
More than 27 years since concerns were first raised, vindication for the families and whistle-blowers
IN 1991, Anita Tubbritt, a staff nurse working nights on an elderly ward at the Gosport War Memorial Hospital in Hampshire, asked to have a quiet word with her local union representative.
Mrs Tubbritt, along with a number of her colleagues, had become concerned over the way medical heroin was being administered to patients, who in their opinion did not require it.
Yesterday, more than 27 years later, those concerns were finally acknowledged, when an independent inquiry concluded that more than 650 patients’ lives could have been prematurely ended by the “institutionalised regime” of prescribing and administering opioids without medical justification.
In arriving at that conclusion, the Right Rev James Jones, who carried out the inquiry, also uncovered almost 30 years of blunders, failures and alleged cover-ups, which leave the NHS, Hampshire Police, the Crown Prosecution Service (CPS), the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) with serious questions to answer.
Making Waves
The nursing staff who first raised concerns about the medical care on the Redclyffe Annexe of the hospital, were worried that patients, who were not in pain, were being placed on syringe drivers, which delivered consistently high doses of diamorphine and other strong opioids.
The nurses described it as using a “sledgehammer to crack a nut” and in virtually every case the patient placed on a syringe driver was dead within three days.
The practice was overseen by Dr Jane Barton, a clinical assis- tant and local GP, who visited daily. Complaints were quickly brought to the management’s attention, including William Hooper, the hospital’s general manager, and Tony Horne and Ian Piper, executives. But the bosses were accused of closing ranks and the nurses were dismissed as being nothing more than a “small group of night staff who are making waves”. Isobel Evans, the patient care manager at the hospital, said the issue had “put a great deal of stress on everyone, particularly the medical staff ”. The nurses were told that Dr Barton was a highly respected clinician and it was suggested that because they were working nights they were not seeing the whole picture.
‘Dead Loss Ward’
While opioids are regularly used on hospital wards, it was the readiness with which they were prescribed on the Redclyffe Annexe, later renamed the Daedalus Ward, that ought to have set alarm bells ringing. International guidelines to ensure the appropriate use of the drugs depending on the patient’s condition, appear to have been entirely ignored, with a powerful trio of opioids often the first course of treatment for patients, regardless of how ill they were.
In some cases patients who had simply been admitted to hospital for respite care were dead days later after being placed on a syringe driver.
In fact, the rate of deaths at the hospital between 1993 and 1998 doubled from around 100 a year to more than 200, before falling off after the departure of Dr Barton. When the pattern was spotted by hospital bosses, it was simply dismissed as either being the result of more patients being admitted, or those who were coming in being more ill and therefore more likely to die.
But one nursing auxiliary, Pauline Spilka, later told police the Daedalus Ward had become known as the “Dead Loss” ward, commenting that the regime was “geared towards euthanasia”.
In his report, Bishop Jones, was critical of some of the nursing staff and also
the consultants, whom he accused of failing to challenge the prescribing culture on the ward. He also highlighted the failure of the hospital’s chief pharmacist to spot unusually high number of opioids being prescribed on wards.
But the report concluded that it was Dr Barton whose role was key in determining how the drugs were prescribed and administered over her 12 years at the hospital.
Criminal investigations
In 1998, the family of Gladys Richards went to Hampshire Police to make a formal complaint after she died during what ought to have been routine rehabilitation following a hip operation.
Over the next three years, three more families went to police. Finally, in 2002, detectives launched an investigation into the deaths of 92 patients.
It took another four years before files on 10 of the deaths were passed to the CPS. But the report found serious failings in the way Hampshire Constabulary handled the allegations, with the families of patients dismissed in some cases as “troublemakers”. The police were also criticised for failing to identify potential witnesses, not taking statements properly and not securing evidence. After meeting two relatives of one victim, Det Con Richard Maddison wrote: “I have no idea why these two sisters are so out to stir trouble.”
In 2006, the family of one patient lodged a formal complaint against Chief Constable Paul Kernaghan over his lack of direction and control.
He retired from the police in 2008 and after spending time with the Palestinian Authority in Ramallah, is now an independent member of the Civil Nuclear Police Authority. The report was also critical of delays in the coronial process, which led to further anguish for the families involved.
David Horsley, the local coroner, expressed concern over the strain that holding 10 inquests would place on his office and staff. He instead suggested Andrew Bradley, a recently retired solicitor, should undertake the role, but both agreed that the inquests should be limited in scope.
The report said the fact neither of the pair considered the deaths at the hospital as raising matters of national importance was “surprising”.
Bias in the GMC?
In 2010, the GMC found Dr Barton guilty of serious professional misconduct but did not strike her off the register and she instead quickly retired. The panel’s report raised questions over why the hearing into her conduct took 10 years to be held from the time she was first reported in 2000 – and why she was allowed to continue to practice during that time. There were also questions raised over the fact her brother, Prof Christopher Bulstrode, was a member of the GMC from July 2003 to December 2008.
While he never sat on any Fitness to Practise panels and was not a council member at the time of her hearing, it later emerged that he had attended a training session with Dr Roger Smith, who sat on the panel at his sister’s hearing five years later. The GMC repeatedly postponed holding a hearing into Dr Barton’s conduct – partly on the request of police.
The report said Dr Barton “benefited from the delay” because she was allowed to continue working. It meant that, by the time her case was considered, she could cite “10 years of good practice to weigh in the balance”. It also pointed out the GMC had evidence about other doctors’ involvement but only chose to pursue Dr Barton.
The local MP
Sir Peter Viggers, the former Gosport MP, also came in for criticism for his “consistent defence” of the hospital and being “consistent in not supporting his constituents in pressing for further investigations”.
Sir Peter failed to raise any of the concerns brought to him by his constituents in Parliament, instead he asked questions only about when existing investigations would be published and how much they had cost. The MP, who was knighted in 2008, had campaigned earlier in his political career to keep the hospital open when it was threatened with closure.
He once described campaigning families as “people [who] had begun to wonder whether they might have something to complain about after their 80 or 90-year-old relatives had died in the hospital”. Sir Peter dismissed concerns raised, not only by families, but by the various inquiries over the years and asked instead for the matter to “be allowed to rest”.
Ann Reeves, whose mother Elsie Devine died at the hospital in 1999, accused the MP of “a lack of action” and ignoring her letters. Other family members complained they were similarly ignored. The former lawyer, who famously claimed for a floating duck island on his MPS’ expenses, was replaced in 2010 as MP by Caroline Dinenage, who campaigned for justice.
‘[Nurses were dismissed as being nothing more than a] small group of night staff who are making waves’