An inquiry into one of the biggest scandals to engulf the NHS found the lives of at least another 200 were shortened.
It said there was an “institutionalised regime of prescribing and administering dangerous doses” of drugs such as morphine via a syringe driver.
This was the trademark method used by discredited clinician Dr Jane Barton, known as “Dr Opiate”. A General Medical Council panel found her guilty of misconduct in 2010 but did not strike her off.
Later the Council for Healthcare Regulatory Excellence said she should have been struck off the medical register. Dr Barton has since retired on a full NHS pension.
Our vulnerable relatives were stripped of their final words to their loved ones, silenced by overdoses.
Three police investigations were held into the deaths at the hospital between 1998 and 2010 but no charges were brought.
In its report yesterday, an independent panel said: “Throughout the three police investigations, a variety of evidence was obtained which, in the panel’s view, indicated that offences under the Health and Safety at Work Act 1974, and/or corporate manslaughter, might have been committed.”
Ann Reeves, whose 88-year-old mother Elsie Devine died at the hospital, said the authorities had conspired to cover up the truth.
“These cases should now go to the Crown Prosecution Service and straight to court,” she said.
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“We shouldn’t be kept waiting any more.”
Bridget Reeves, 42, Elsie’s granddaughter, said: “None of us would have allowed our loved ones to be admitted to that hospital had we known there was a police investigation going on.
“This inexcusable failure is not only shameful, it is scandalous and it is immoral. Our vulnerable relatives were stripped of their final words to their loved ones, silenced by overdoses. This sort of behaviour going on in our NHS is chilling.
“It has been sinister, calculated and those implicated must now face the rigour of the criminal justice system. Only then can we put our loved ones to rest.”
The scale of the scandal was fi nally exposed yesterday – 27 years after concerns were first raised in 1991 but ignored.
Nurses’ warnings of an “institutionalised practice of shortening lives” were dismissed, according to the panel’s report.
The £13million probe, led by the former Bishop of Liverpool, James Jones, who oversaw the Hillsborough inquiry, found there was a “catalogue of failings” from a host of public bodies, some of which closed ranks in order to protect professional reputations.
The panel did not apportion blame but its 400-word report found a “disregard for human life and a culture of shortening of lives of a large number of patients”.
For 12 years during a period in which there was a horrifying spike in deaths between 1988 and 2000, Dr Barton was responsible for the practice of prescribing that prevailed on the wards. Concerns were raised by whistleblowers in 1991 but were “systematically ignored”.
Families raised their concerns in 1998 but they were dismissed too.
The report revealed there was a perception that Dr Barton might be a “lone wolf” or “rogue doctor” operating without authorisation that “rapidly took root with both the police and NHS bodies”.
Health watchdogs failed to intervene, professional regulators allowed matters to continue and the police repeatedly failed to get to the bottom of what had happened.
In what was described by one grieving relative as a collective stitch-up by hospital management, Hampshire Police, the Crown Prosecution Service, the General Medical Council and Nursing and Midwifery Council all failed to act.
Brigette Reeves speaking on behalf of victims
Health Secretary Jeremy Hunt said: “The findings can only be described as truly shocking. Nothing I say will lessen the anguish and pain of families who have campaigned for 20 years for justice. But I can at least on behalf of the Government and NHS apologise for what happened. Had the establishment listened when junior staff spoke out, when ordinary families spoke out instead of treating them as troublemakers, many of these deaths would not have happened.
“The police, working with the CPS and clinicians as necessary, will now carefully examine the new material in the report before determining their next steps and in particular whether criminal charges should now be brought.”
Bishop James said: “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 then be forthcoming.
“Throughout, the relatives have shown remarkable tenacity and fortitude in questioning what happened to their loved ones.”
At Prime Minister’s Questions Theresa May said the events at the hospital were deeply troubling and had brought unimaginable heartache to the families concerned.
Hampshire Police chief constable Olivia Pinkney said: “We will assess any new information in the report in conjunction with our partners in the Crown Prosecution Service in order to decide the next steps.”
August 1998 – Gladys Richards dies in Gosport War Memorial Hospital after going in for rehabilitation following a hip operation. Family report concerns about her treatment to the police and coroner.
2001 – Three more families go to police and two more cases were reported to the NHS ombudsman.
July 2002 – The Commission for Health Improvement (CHI) criticised Portsmouth Healthcare NHS Trust, which ran the hospital, for excessive use of pain relief and sedative drugs.
February 2005 – Hampshire Police pass files of evidence to the Crown Prosecution Service (CPS) about the deaths of elderly patients.
December 2006 – Hampshire Police announce that no-one will face prosecution over the deaths of patients at the hospital after a four-year inquiry.
April 2009 – An inquest jury rules drugs given to five elderly people at the hospital contributed to their deaths.
January 2010 – The General Medical Council finds Dr Jane Barton guilty of serious professional misconduct by a Fitness to Practise panel. Instead of being struck off she was given a list of 11 conditions relating to her practice, including not being able to administer opiates by injection.
March – Dr Barton retires from medical practice.
August – The CPS announces that no criminal charges are to be brought against Dr Barton.
September – Ann Reeves, the daughter of 88-year-old Elsie Devine, leads a protest march to Downing Street.
April 2013 – A coroner rules that medication given to Mrs Richards contributed “more than insignificantly” to her death.
July 2014 – An independent investigation into more than 90 deaths at the hospital is launched and due to conclude in 2017.
2016 – The inquiry is extended and its publication date is put back to 2018. June 20 2018 – The inquiry is published.
The doctor at the centre of the Gosport scandal is believed to have travelled to Spain before the report’s release. Former GP Jane Barton, nicknamed “Dr Opiate”, was responsible for administering high doses of drugs to patients admitted to Gosport War Memorial Hospital.
There were so many deaths under her watch, the two wards she ran at the Hampshire hospital became known as “the end of the line”.
The £700,000 pale brick house she shares with her husband Tim, a former Royal Navy commodore, in the Alverstoke area of Gosport, yesterday stood empty. Neighbours suggested Dr Barton, 69, had gone to Spain.
A neighbour said: “She doesn’t have many friends around here.”
‘Brusque, unfriendly and indifferent’…Dr Barton
Another neighbour shouted: “She’s gone to Menorca.”
Dr Barton, who graduated from Oxford in 1972, was found guilty of “multiple instances of serious professional misconduct” by the General Medical Council (GMC) in 2010.
She was not struck off but soon retired. Much of the evidence concerned her “brusque, unfriendly and indifferent” manner, her “intransigence and worrying lack of insight” into the effects of her actions and her inability to “recognise the limits of her professional competence”.
After the GMC findings, the Crown Prosecution Service said there was insufficient evidence for a gross negligence manslaughter prosecution.
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Dr Barton was clinical assistant at the hospital from May 1988 until she resigned in April 2000. She was previously a GP in Dorset and Gosport. At the Gosport hospital, she dealt with patients who needed more care than nursing homes could provide.
At the GMC hearing, which ended in 2010, she produced 200 testimonials from other medics and local patients. Her lawyers insisted she was a “good doctor”, and she pleaded that caring for increasing numbers of elderly had put her and other staff under “unreasonable pressure”.
She was found guilty of professional misconduct, criticised for prescribing strong drugs in an “excessive, inappropriate, potentially hazardous” way, and barred from giving opiate injections. Established to address concerns about the deaths of elderly patients, the inquiry’s work included looking at 833 death certificates signed by Dr Barton and examined more than one million pages of documents.
The prosecution of GP Harold Shipman, who was jailed in 2000 for murdering 15 patients, “cast a long shadow”, the report said, which meant police considered if Dr Barton could be another Shipman and looked only at whether she was guilty of unlawful killing, instead of pursuing a wider investigation.
Victim: Geoffrey Packman
Rhoda Cunningham and husband Arthur
SHEILA GREGORY, 91
Sheila was admitted to the Gosport War Memorial Hospital in September 1999 after a fall. She died two months later aged 91. An inquest heard the dose of morphine administered by Dr Barton via a syringe driver could be considered to be at the upper limit but was not exceptional in the circumstances.
ARTHUR CUNNINGHAM, 79
Widower Arthur had Parkinson’s disease and was admitted for treatment for bed sores. He was expected to return to his nursing home but five days later was dead. On his first night he became agitated and was given diamorphine to calm him. The dose was increased four-fold over the next few days. His stepson Charles Farthing said: “Dr Barton was utterly reckless in her prescribing.” His wife Anne said: “He did not deserve to be put down like a dog.”
ROBERT WILSON, 74
Robert Wilson was hospitalised with a fractured shoulder but did not like the amount of drugs he was given. A day after being admitted, he told his son Iain doctors were killing him. In 2009, his son told an inquest: “I said, ‘No they are not dad, they are trying to do their best for you’. The following day he was in a coma.”
Victim: Robert Wilson
Victim: Elsie Devine
STANLEY CARBY, 65
Former Naval officer Stanley was 65 when he went in for rehabilitation after a series of mini-strokes. His daughter Debbie Mackay said: “He wasn’t in any pain and was on nothing stronger than aspirin.” But he was put on morphine and died the next day. Mrs Mackay, pictured with her sister Cindy Grant, left, said: “We knew something wasn’t right straight away.”
ELSIE DEVINE, 88
Elsie Devine, 88, from Farnham, Hants, was admitted with confusion and kidney problems. Her notes showed she had been sitting up and chatting happily but she was given powerful sedatives, lost consciousness and never recovered. A jury found medication contributed to her death.
GEOFFREY PACKMAN, 68
Geoffrey Packman, known as Mick, was one of the youngest. He was 68 when he died after being admitted with leg ulcers on August 23, 1999. He died there on September 3. Daughter Vicky said he was sent in just for rehabilitation and mobilisation. She told a 2009 inquest that he soon became a vegetable and just slept.
Victim: Sheila Gregory
Family of victim: Stanley Carby
THE CAMPAIGNER: My 20-year fight to prove mum was given overdose
It was Gill MacKenzie’s stubborn refusal over almost 20 years to accept that her mother had died of old age that sparked an independent investigation into the Gosport scandal. Haunted by the death of her husband from cancer at the age of 48, she suspected her 91-year-old mother, Gladys Richards, had been unlawfully killed and called the police.
She believed her mother was prescribed too much morphine and yesterday her initial suspicions were vindicated. Mrs MacKenzie, who was struck down with breast cancer 18 months ago and told she was too old for chemotherapy, never thought she would live to see the publication of the inquiry report.
In 2000, GP Harold Shipman was found guilty of 15 murders for killing patients under his care.
He was sentenced to life and hanged himself in prison four years later.
Mrs MacKenzie wants to see those responsible for the latest scandal hauled before the courts. She said: “I want to see criminal proceedings. The strongest 15 cases should be heard in a criminal court and there should be convictions and as far as I am concerned that will be justice. My God, they will hear from me if that doesn’t happen. I might not be alive because of the cancer, but I didn’t think I would be here to see the report published. I’m like my mum, I am determined.”
Mrs Mackenzie, 84, of Eastbourne, East Sussex, told police she wanted to make an allegation of unlawful killing. But the Hampshire force, which was criticised for its handling of relatives’ complaints about the hospital, decided to take no action.
The publicity her fight raised led to other families concerned about the circumstances in which their loved ones died coming forward and a campaign was born. Mrs Richards dislocated her right hip in a fall and was recovering from a hip replacement operation at Gosport hospital.
Her doctors from Haslar hospital were hoping she would get back on her feet after some recuperation at Gosport and wrote in her notes: “Despite her dementia she should be given the opportunity to try to re-mobilise.”
Dr Jane Barton wrote in the records as she was admitted: “Not obviously in pain. Please make comfortable. I am happy for nursing staff to confirm death.”
Gillian Mackenzie holding a photo of her mum Gladys
She died four days later. Mrs Richards, of Lee-on-Solent, died from overdoses of diamorphine, haloperidol, hyoscine and midazolam on August 21, 1998.
The investigating panel wrote: “The administration of diamorphine 40mg over 24 hours by syringe driver in a patient who had received 45mg of morphine oral solution in the previous 24 hours constitutes more than double the effective dose of morphine.
“The panel can find no justification in the clinical records for this increase in dosage.” Mrs Richards’ recommended drug treatment was haloperidol suspension, lactulose and co-codamol. Her daughter said: “The whole attitude towards dying patients was not correct at that hospital. “I knew something wasn’t right and I asked questions. People wouldn’t listen to me at first.”
Read more here: Daily Express :: Health Feedhappy wheels
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