Chapter 12: Summary and conclusions
Summary of the chapters
The Terms of Reference require the Panel to explain how the documents it has considered add to public understanding of what happened at the hospital. Each of the chapters in this Report concludes by identifying those points of public understanding that can now be seen clearly and for the first time.
The Panel has interrogated the documents. Each chapter of this Report describes what the documents say about what happened at the hospital and how the responsible authorities chose to respond. The chapters explain what is added to public understanding in the case of the hospital and each of those authorities.
Chapter 1 shows that, following concerns first raised by Anita Tubbritt (a staff nurse working on Redclyffe Annexe), Sylvia Giffin, a fellow staff nurse, wrote to their manager in February 1991 expressing concern over the prescribing and use of drugs with syringe drivers.
The documents the Panel has reviewed show that between then and January 1992, a number of nurses raised concerns about the prescribing specifically of diamorphine. In doing so, the nurses involved, supported by their Royal College of Nursing branch convenor, put the hospital in a position from which it could have rectified the practice. In choosing not to do so, the opportunity was lost, deaths resulted and 22 years later it became necessary to establish this Panel in order to discover the truth of what happened. The documents therefore tell a story of missed opportunity and warnings unheeded.
Chapter 2 describes the drugs that were prescribed, including diamorphine, and the pattern of anticipatory prescribing that became the norm at the hospital. The occurrence of opioid use without appropriate clinical indication followed a clear pattern over time. We found no instances of this in 1987 or 1988, but from 1989 the number of cases rose markedly and then reached a plateau between 1994 and 1998. This was followed by an equally striking decline over 1999 and 2000, with no instances in 2001. Within the period 1989 to 2000, lives were shortened to the extent described in Chapter 2, see Figure 2, and earlier in this chapter.
Chapter 3 uses case studies to illustrate the experience of patients and relatives at the hospital. As well as confirming the pattern of prescribing and administration of drugs, Chapter 3 demonstrates the sub-optimal care and lack of diligence by nursing staff in executing their professional accountability for the care delivered. Patients and relatives were marginalised and their interests became subordinate to those of the professional staff.
Chapter 4 shows how the relevant healthcare organisations failed to recognise what was happening at the hospital and failed to act to put it right.
Chapter 5 sets out how Hampshire Constabulary dealt with the allegations made by the families, the shortcomings of the investigations, and the cases that were presented to the Crown Prosecution Service. The chapter explains that, although the investigations were protracted, they were limited in their depth and in the range of possible offences pursued. The documents show the involvement of senior officers including at chief officer level. The chapter also describes the response of the CPS, including the limitations in considering the possibility of corporate liability and health and safety offences.
The GMC’s primary purpose is to protect patients. Chapter 6 shows that concerns about the hospital were brought to the attention of the GMC in 2000. It also describes the circumstances that meant there was a ten-year delay before the GMC’s Fitness to Practise Panel considered sanctions against Dr Jane Barton, clinical assistant at the hospital.
The NMC’s main objective is to safeguard the health and well-being of people using or needing the services of its registrants. Chapter 7 demonstrates a similar pattern with the NMC as the statutory regulator for nurses. From the point of referral to its predecessor body, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, in 2000, it would take ten years for the Preliminary Proceedings Committee to decline to proceed in respect of all the allegations against the nurses concerned.
Chapter 8 shows how the Coroner and Assistant Deputy Coroner proceeded with inquests nearly two years after the Crown Prosecution Service had decided not to prosecute.
Chapter 9 describes how the local and national media covered concerns about the hospital from April 2001 onwards. This was over two and a half years after Gillian Mackenzie and others contacted Hampshire Constabulary, thereby setting in motion the police investigation. The documents illustrate the sometimes close relationship between the police and the media, and how the police and healthcare organisations made contact with each other when the media raised questions.
Chapter 10 describes how Sir Peter Viggers, the local MP, questioned the need for repeated inquiries into what had happened at the hospital.
Chapter 11 describes the work of the Panel in delivering its Terms of Reference, and sets out the Panel’s concerns about standards of record keeping and missing material.