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Gosport Independent Panel

Chapter 5: Hampshire Constabulary and the Crown Prosecution Service

Conclusion: what is added to public understanding

  • The nurses’ concerns about the prescribing and administering of drugs at Gosport War Memorial Hospital (‘the hospital’) are described in Chapter 1 of this Report. The Panel has found no documents indicating that Hampshire Constabulary, the relevant police force, was made aware of these concerns. Nor do the papers show any approach to Hampshire Constabulary in the period up to 1998. 
  • Between 1998 and 2010, Hampshire Constabulary conducted three investigations and engaged with the Crown Prosecution Service.
  • The documentation available to the Panel shows the action taken by the police to assess the validity of the concerns being raised by Gillian Mackenzie and Lesley Lack, Gladys Richards’ daughters. The report by Detective Constable (Det Con) Richard Maddison consisted of a reiteration of the notes taken by Mrs Lack. Potential witnesses were not identified, no statements were taken, no contact was made with the hospital to secure clinical notes, records or evidence, or the investigation report by Lesley Humphrey (Director of Quality at Portsmouth HealthCare NHS Trust), which contained early accounts from nursing staff. No scene visit was undertaken, no forensic evidence was considered and no thought was given to the possibility of looking into other patient records for similar issues. Nor were any investigative steps taken to secure best evidence. This was particularly important given that Mrs Richards had been cremated and therefore could not be the subject of a post mortem and toxicology report. There was also no attempt to seek advice from the Crown Prosecution Service.
  • There is nothing in the records to suggest that either the police or the Crown Prosecution Service considered the need to instruct Counsel for advice or reflected upon the inadequacy of this investigation. Nor is there any reference to the Code for Crown Prosecutors. The documents suggest that no consideration was given to the range of potential offences and defendants or to the possibility that there were other similar cases at the hospital.
  • The documents do not show that Hampshire Constabulary made any consideration of steps they might have taken to address any ongoing risk to patients at the hospital. The police did not take action to identify the other cases that might have been involved and they continued with a paper-based investigation rather than switching to a computer-based HOLMES account as proposed in the briefing note. The papers do not show any consideration of establishing a Gold Group, through which the investigation could be effectively managed and coordinated. 
  • Professor Livesley completed his first report. In doing so,he made it clear that his report, dated 9 November 2000, was provided for discussion only and that he required a conference with the Crown Prosecution Service and Counsel before finalising his report. He expressed serious concern about what appeared to be “a culture of inappropriate clinical practice".
  • There is no evidence of the police taking any action to pursue Professor Livesley’s recommendation in respect of other patients at the hospital or to consider issues of corporate liability. 
  • On 31 May 2001, David Perry QC advised, in writing, that having considered the case of Gladys Richards the “evidence does not reveal the commission of any offence"
  • Despite the concerns that had been raised by Professor Livesley, Dr Keith Mundy (consultant geriatrician) and Professor Gary Ford (a medical professor at Newcastle University), on 28 January 2002 Detective Superintendent James took the decision to end the police investigation, which he recorded as follows: “SIO’s decision re wider police investigation into deaths at Gosport War Memorial Hospital is that further investigation would not be appropriate". The reasons given for reaching this decision were the lapse of time since Det Con Maddison’s initial report from 5 October 1998, the lack of evidence of any unlawfulness having occurred, conflict between experts, the lack of certainty of any particular outcome and the fact that other agencies (such as the General Medical Council) have a role.
  • The Panel has seen no documents providing details of meetings, briefings or other considerations leading to the decision to close the second investigation. No closure report has been disclosed. Moreover, the documents indicate that the decision to end the investigation was not discussed with the Crown Prosecution Service. 
  • The documents show that there were a series of events described in this chapter that obliged Hampshire Constabulary to reverse their decision and to institute a further investigation.
  • The documents confirm that, during the third investigation, new complaints and concerns relating to patient care and deaths at the hospital were reported to the police, who considered the deaths of 91 patients. 
  • The Panel has not seen any document to confirm on what basis the police determined that no offences had been committed in respect of the 1991 events. The Panel notes that the investigation into the 1991 events was incomplete in that the police had not sought to establish the specific details of the nurses’ concerns, the chain of command on the wards and the hospital, and the persons responsible for implementing the use of syringe drivers and diamorphine. The police also did not enquire into staff training and senior-level knowledge and involvement in the response to the nurses’ concerns. In addition, Hampshire Constabulary did not enquire into the result of the Strategic Health Authority-commissioned management investigation. Following the decision that no offences had been committed in respect of the 1991 documents, the police did not invite the Strategic Health Authority or Commission for Health Improvement to reinstate their investigation.
  • Mr Perry’s advice did not extend to the possibility that offences may have been committed by Dr Barton and others, including the Trust, under health and safety legislation. The Panel has seen no evidence to indicate that full consideration was given to whether such offences had been committed. 
  • The Panel notes that, during the course of all three investigations, the need to look into corporate liability and health and safety offences was brought to the attention of senior police personnel and the Crown Prosecution Service. Hampshire Constabulary sought legal advice on these issues but the documents suggest that neither the case for corporate prosecutions nor the case for bringing prosecutions under health and safety legislation was fully or properly considered.
  • 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. Among other matters, Professor Livesley had raised the possibility that any wrongdoing might be wider than one patient and one doctor.
  • As a general observation, the Panel notes that the more complex an investigation, and the greater the scale, the more likely it is that investigative advice and guidance will be required by the police from the Crown Prosecution Service. In a case as complex and novel as this one relating to the hospital, there may have been an increased need for regular and constructive liaison between the police and the Crown Prosecution Service but this does not appear to have been the case.
  • It is clear from the documents that family members felt that Hampshire Constabulary’s level of communication was inadequate.