Foreword by The Right Reverend James Jones KBE
When I first came to Gosport and met those who had historical concerns about how their loved ones had been treated in the town’s War Memorial Hospital, there were eight families. Once the Independent Panel had been set up, we were soon in touch with over 100 families. The shocking outcome of the Panel’s work is that we have now been able to conclude that the lives of over 450 patients were shortened while in the hospital, and to demonstrate that those first families were right to persist in asking questions about how their loved ones had been treated.
Over the many years during which the families have sought answers to their legitimate questions and concerns, they have been repeatedly frustrated by senior figures. In this Report, we seek to understand how and why this has happened. The obfuscation by those in authority has often made the relatives of those who died angry and disillusioned. The Panel itself felt some of that frustration directed towards ourselves at the beginning of our work. The families had already been let down so often that they saw no reason why they should trust a Panel set up by the Government, albeit an independent one.
Some of the family members are the first to acknowledge that their quest for truth and accountability has had an adverse effect on their own lives. They know that the frustration and anger that they feel has sometimes consumed them. This in turn has no doubt made those in authority less inclined to build a bridge towards them and to investigate their concerns thoroughly. But what has to be recognised by those who head up our public institutions is how difficult it is for ordinary people to challenge the closing of ranks of those who hold power.
It is a lonely place, seeking answers to questions that others wish you were not asking. That loneliness is heightened when you’re made to feel even by those close to you that it’s time to get over it and to move on. But it is impossible to move on if you feel that you have let down someone you love, and that you might have done more to protect them from the way they died. Many of the families to whom the Panel has listened feel a measure of guilt, albeit misplaced.
The anger is also fuelled by a sense of betrayal. Handing over a loved one to a hospital, to doctors and nurses, is an act of trust and you take for granted that they will always do that which is best for the one you love. It represents a major crisis when you begin to doubt that the treatment they are being given is in their best interests. It further shatters your confidence when you summon up the courage to complain and then sense that you are being treated as some sort of ‘troublemaker’.
Many of the family members from Gosport have a background in the services. They were brought up to believe that those in authority are there to serve and to protect the community. The relatives did not find it easy to question those in senior positions. It says something about the scale of the problem that, in the end, in spite of the culture of respecting authority, the families, as it were, broke ranks and challenged what they were being told about how their loved ones were treated and how they died.
This Report is a vindication of their tenacious refusal to be dismissed. It shows how they were failed by the professional bodies and by others in authority charged with responsibility for regulating the practice of professionals in the interests of patient safety.
The documents that the Panel has found reveal that, as demonstrated in Table 1 at the end of the Report, during a certain period at Gosport War Memorial Hospital, there was a disregard for human life and a culture of shortening the lives of a large number of patients by prescribing and administering “dangerous doses” of a hazardous combination of medication not clinically indicated or justified. They show too that, whereas a large number of patients and their relatives understood that their admission to the hospital was for either rehabilitation or respite care, they were, in effect, put on a terminal care pathway. They show that, when relatives complained about the safety of patients and the appropriateness of their care, they were consistently let down by those in authority – both individuals and institutions. These included the senior management of the hospital, healthcare organisations, Hampshire Constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and the Nursing and Midwifery Council. All failed to act in ways that would have better protected patients and relatives, whose interests some subordinated to the reputation of the hospital and the professions involved.
In the relationship with these powerful public bodies, the families have felt powerless. The Panel’s Report gives voice to their historical concerns and substantiates them.
The Panel – in submitting the Report to the Secretary of State for Health and Social Care in order for it to be laid before Parliament on Wednesday 20 June 2018 – expects the relevant individuals and authorities from whom documents were sought to address these historical concerns that the families have carried for over 20 years.
The Right Reverend James Jones KBE
Chair, Gosport Independent Panel