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Gosport Independent Panel

Chapter 4: Healthcare organisations and individuals

Conclusion: what is added to public understanding

  • In 1998, a complaint was made about the treatment of Mrs Richards, who died on 21 August 1998. The investigation report shows that William (Bill) Hooper commissioned the investigation. The investigation report included reference to medication administered via a syringe driver, but this was not identified as one of the questions raised by the complaint, and the report did not identify the contents of the syringe driver (diamorphine, midazolam, hyoscine and haloperidol). Mr Hooper, who commissioned and presumably received the report, was one of the managers involved in the response to the nurses’ concerns over opioid use six years previously.
  • An internal briefing was produced within the Department of Health on 5 April 2001, following local press coverage. The briefing identifies factors common to three complaints, including the responsible consultant and the clinical assistant. It concludes that “there is not sufficient evidence, at this time, to suggest that these deaths are linked or are the result of foulplay". 
  • There is no documentary evidence that either the Health Authority or the Trust, or their successor organisations, conducted any systematic investigation of these events. 
  • On 16 July 2002, Sir Liam Donaldson briefed senior officials and Ministers that, following the Commission for Health Improvement investigation, he had “concerns that there are some aspects of the case that are still unclear [and] I believe we should consider further investigation”. He proposed that Professor Richard Baker should conduct “an NHS investigation initially examining data to look for evidence of excess mortality or clusters of deaths”. 
  • On 16 September 2002, a meeting was held in the hospital to brief staff about Professor Baker’s review. This was led by Lucy Docherty, Chair of Fareham and Gosport Primary Care Trust. While waiting for the meeting to start, a senior nurse, Toni Scammell, was approached by Staff Nurse Anita Tubbritt and Nurse Beverley Turnbull and handed a folder of documents dating from 1991/92, covering the nurses’ concerns described in Chapter 1 of this Report. She realised the implications immediately: “When I read the minutes I felt sick. I considered the minutes to be very damming.”
  • From the documents reviewed by the Panel, it appears that the approach made to Nurse Scammell on 16 September 2002 was the first time that healthcare organisations other than the Trust were aware of the warnings the nurses had made 11 years earlier to previous NHS managers, warnings that had gone unheeded in the intervening period. 
  • Over the next two days there was “much debate” between senior officers of the Strategic Health Authority and the Directorate of Health and Social Care (a short-lived body that succeeded the Regional Office), culminating in a decision to commission an investigation into why the information in the dossier had not emerged since 1992. At the same time the decision was taken to suspend two managers who appeared to have been involved in the 1991/92 events. The two were Ian Piper, now Chief Executive of Fareham and Gosport Primary Care Trust, and Tony Horne, now Chief Executive of East Hampshire Primary Care Trust. 
  • The note records a detailed description of the contents of each box. This shows that the boxes included all of the most important papers from Portsmouth HealthCare NHS Trust over the period 1994–2002, including Board papers, Executive Team meeting papers and Clinical Management Group meeting papers. Appended is another manuscript note, “Box taken by R Samuel (SHA) 20 November 2002”, signed by Mr Richard Samuel, Assistant Chief Executive Officer of the Strategic Health Authority. The Strategic Health Authority, when reviewing the subsequent management investigation, described these boxes, which are missing from the material made available to the Panel, as including “a number of papers that are relevant to the investigation".
  • On 6 December 2002, Gareth Cruddace wrote to Sir Liam confirming that the Strategic Health Authority and the two Primary Care Trusts (East Hampshire and Fareham and Gosport) “have commissioned an independent internal management investigation into events at Gosport War Memorial Hospital between 1988 and 1998 in order to decide whether disciplinary action should be taken in relation to senior managers and clinical managers”. This was to be undertaken by Michael Taylor, formerly Chief Executive of Oxfordshire Health Authority, and the Terms of Reference “have previously been … agreed with the Police". 
  • The record of a meeting on 17 January 2003 states that “the management investigation should be suspended and that the second CHI investigation should not proceed … the CMO had agreed that the second CHI investigation would stop”. Following a three-hour discussion as recorded in the meeting notes, the management investigation was to be suspended and the redeployed Chief Executive Officers, Mr Piper and Mr Horne, would be invited to return to their Chief Executive Officer positions.
  • Although the second Commission for Health Improvement investigation had not started before it was placed on hold, the management investigation had completed enough work to produce an initial report. Mr Taylor set out the conclusions in uncompromising terms.
  • While the management investigation remained on hold, Sir Liam had said on 1 October 2002: “Previous experience has shown that once a NHS investigation is halted by a Police investigation, then it can take years to start again. We cannot afford for this to happen.” The records show that these remarks were prescient. The management investigation would never be restarted. The second Commission for Health Improvement investigation was never undertaken.
  • The records show that the Department of Health used a number of different Freedom of Information Act exemptions to resist publication of the Baker Report until legal advice was received in July 2013 that it should be published.