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Gosport Independent Panel

Chapter 12: Summary and conclusions

The response of individuals and organisations: what is revealed about focusing on an individual ‘rogue doctor’ following Shipman


A perception rapidly took root with both the police and NHS bodies external to the Trust that Dr Barton might be a ‘rogue doctor’ or ‘lone wolf’, operating surreptitiously and without authorisation. It is impossible to miss the significance of the relatively recent conclusion to the Shipman case at the time, and there are several references, direct and oblique, to the Harold Shipman case in documents briefing Ministers. It is notable that the Chief Medical Officer selected Professor Richard Baker to carry out the external audit of deaths in significant part because he had carried out a similar audit in connection with the Shipman investigation.


This perception, that the events might be due to ‘another Shipman’, cast a long shadow. Hence, even in 2007 when the final police investigation concluded, the obvious next step seemed to be to resume the GMC professional regulatory process against Dr Barton. The culmination of that process clearly dissatisfied many, including the GMC’s Chief Executive. However, the outcome was at least in part due to the exclusive focus on one individual when there were significant systemic problems – as the proceedings began to reveal – as well as the length of time that had elapsed by then.


It is clear from the documents that awareness of the Shipman case cast a shadow over how concerns at the hospital were viewed. Shipman was first arrested in September 1998. Whether for that reason or for some other reason, the police focused on the allegation that Dr Barton was guilty of unlawful killing, rather than pursuing a wider investigation. Hampshire Constabulary approached Dr Barton’s managers, including the then Chief Executive at the Trust, and Dr Althea Lord, the responsible consultant, in a way that ignored the possibility that they too might have been subject to investigation.

The response of the police: what is revealed about their approach and priorities


Chapter 5 reveals the approach taken by Hampshire Constabulary throughout its three investigations. It is no surprise to the Panel that the police approach failed to satisfy the families from the start. The documents show that the quality of the police investigations was consistently poor.


From the start, the mindset was one of seeing the family members who complained as stirring up trouble, and seeing the hospital, by contrast, as the natural place to go for guidance and assurance. As such, the police did not attempt to conduct enquiries in the same way as they would have done in a different setting; that is, one not involving medical decisions and treatment given in a hospital. The documents show that the police viewed the allegations as matters for the Trust and the regulatory bodies.


In reviewing the documents, the Panel has been mindful of how police forces set their priorities for investigation and for resources. In particular, in the period covered by this Report, both national and local targets informed that process of prioritisation. There are no documents referring to any decisions within Hampshire Constabulary to place less emphasis on their investigations into the hospital than on other activities that would have scored against any such targets. However, the Panel notes that organisations tend to favour acting in ways that are relevant to how they are measured or judged.


More generally, the evidence in this case suggests that, faced with concerns amounting to allegations of unlawful killing in a hospital setting, there are clear difficulties for police investigation. It is not clear to the Panel how the police can best take forward such investigations, and how they are to know whose advice to seek from within the health service without compromising their enquiries. This is particularly significant if the problem concerns the practice on a ward where more than one member of a clinical team is involved. It is a need that calls for action across different authorities, rather than a matter for the police service in isolation.

The response of individuals and organisations: what is revealed about wrongly relying on professional regulatory bodies


This exclusively individual focus by the police led to a continuation of the bar on investigating or sharing results pending completion of the regulatory process, in order to prevent the case being jeopardised. It also reinforced the perception that there were no systemic issues to be addressed locally and thus no further reason to investigate. This, however, reflects a prevalent but incorrect view of the function of professional regulators like the GMC. Their function is neither to investigate systemic health service failures nor to punish errant doctors; rather, it is to protect the public by regulating the current fitness to practise of registered medical practitioners. Hence, even though the GMC found that there had been impairments to Dr Barton’s fitness to practise, strictly speaking it was entitled to find that she was not a danger to patients by the time the hearing had been completed. The distress caused to families by the outcome of the GMC proceedings arose in part from the exclusive reliance of NHS bodies on the GMC, when it was not in fact an appropriate sole mechanism.

The response of individuals and organisations: what is revealed about suspending effective action pending police investigation


The documents illustrate the effect of the police investigations on all the external health service organisations. All concerned assumed not only that the police investigations took priority, but that they prevented any other investigations from proceeding. There were only two exceptions: the management investigation into the actions of managers who had failed to admit knowledge of the nurses’ dossier (which was halted after its initial phase because another police investigation was under way) and the Baker Report (which was entirely records-based and could be carried out without requiring wider knowledge of the findings). Otherwise, not only were no investigations commissioned, but it appears (from their responses) that most NHS organisations were reluctant even to mention the problem.


This has been a common occurrence when police investigations into NHS services take place, and there are valid concerns. If interviewees are asked about events, if they talk to others and if they see or hear potential findings, their evidence would be regarded as contaminated by prior knowledge if a case came to court. The documents in this case make clear that at several points the police communicated this view and its attendant warning widely to national and regional health service bodies. It is clear that none wanted to risk any possible subsequent case being thrown out because they had failed to observe this precaution.


When the police investigations subsequently concluded without prosecutions, this bar was removed. It is notable, however, that there was still no effective NHS action. There are some obvious reasons for this, although none fully explains the failure to grasp a problem of this magnitude and significance.

The response of individuals and organisations: what is revealed about the use of experts


As noted earlier in this chapter, and in Chapters 4 to 8, a number of experts were engaged, including by the police, the NHS, the Chief Medical Officer and the Coroner. The documents show that none of these experts had access to the full range of medical records to which the Panel has had access, and they are therefore not responsible for the failure of the full picture to appear clearly until now. A more detailed review of the use of the experts is available in the Expert Overview on this website.


The documents reveal weaknesses in how the experts were commissioned: there was sometimes no clarity on their remit and insufficient focus on the relevant specialist expertise required.


At times, the documents reveal a misuse, not just of the experts’ opinions, given in good faith, but of the experts themselves. This, along with the poor standards in commissioning experts and making use of their contribution, points to a need for a more professional framework for the use of experts.