Chapter 7: The Nursing and Midwifery Council
The Nursing and Midwifery Council investigation: before Operation Rochester
On 21 June 2001, the Fareham and Gosport Primary Care Trust (PCT) responded to a letter from the UKCC. It described the circumstances of Mrs Richards’ admission to the hospital, the complaint that the family had made to the PCT and the investigation that the PCT subsequently undertook (DOH700267). On 27 July, the PCT provided the UKCC with the material generated as a result of the complaint made to the PCT by Mrs Lack (DOH102868). This included the letter from Mrs Lack as well as the PCT’s investigation report, which found no evidence of wrongdoing by any of the nurses (NMC100090, p222).
On 14 August, Hampshire Constabulary informed the UKCC that, following advice from the Crown Prosecution Service, no criminal prosecutions would be brought against the three relevant nurses (HCO003876).
On 18 September, the PPC of the UKCC convened to consider the cases of these nurses in relation to the treatment of Mrs Richards at the hospital. The PPC represented the first of a two-stage process which applied at the time (NMC100090, pp1–10).
The PPC carried out the following functions:
- investigations into cases of alleged misconduct
- determination of whether or not to refer a case of alleged misconduct to the Professional Conduct Committee with a view to removing practitioners from the register
- determination of whether or not to refer a case of alleged misconduct to professional screeners for consideration of a practitioner’s fitness to practise
- determination of whether a practitioner was guilty of misconduct and, if so, whether it was appropriate to issue a caution as to their future conduct.
The PPC noted that the referral had been made by Hampshire Constabulary as part of the criminal investigation into the circumstances of Mrs Richards’ death. It was noted that the family’s main concerns were as follows:
“1. On 12 August when first admitted to Gosport her agitation was put down to dementia when in fact it could have been simply that she wanted the toilet. She could have been treated with a milder form of pain relief.
2. When she suffered her fall a doctor should have been called before she was moved back to her chair.
3. On 13 August, it took a long time for staff to identify that she had suffered a fall. Her distress was continually put down to her dementia and she was not admitted to Haslar A and E until 24 hours after the fall.
4. On 17 August when she was returned to Haslar Hospital she was obviously in extreme pain from being positioned wrongly. Why was nothing done about this until Mrs lack arrived and assisted the nurse to move her.
5. When Mrs Richards developed a haematoma why was a decision made to do nothing other than to keep her pain free.” (NMC100090, p8)
The UKCC report noted that no specific allegations had been made against the three practitioners but identified concerns raised by Mrs Richards’ family in respect of the conduct of each nurse. The UKCC report proposed that, for the following reasons, no action should be taken against the nurses:
“1. The police are not proceeding with any criminal prosecution of any practitioner.
2. The Trust’s findings do not support any allegations of misconduct.
3. The family’s complaints are mainly about the medical treatment received by Mrs Richards, although they have identified some mistakes and delays in the system their evidence does not provide proof to the required standard of professional misconduct by any practitioner.” (NMC100090, p9)
Under the process in place at the time, when the UKCC had investigated a case and considered that it might lead to the removal of a practitioner from the register, it would write to the practitioner involved and then consider referral to the Professional Conduct Committee. In this case, the UKCC decided to take no further action.
The Panel notes that the PPC relied upon the Trust’s findings and upon the decision not to take criminal proceedings rather than conducting its own enquiries. Mrs Richards’ family were not informed of the decision of the PPC because they were not considered to be the complainants (NMC100090, p6).
On 6 February 2002, Hampshire Constabulary disclosed to the UKCC expert reports prepared by Professor Livesley, Dr Keith Mundy, a consultant geriatrician, and Professor Gary Ford, a medical professor at Newcastle University (HCO003853). At the same time, the reports were disclosed to the Hampshire and Isle of Wight Strategic Health Authority (HCO501408). On 11 February, Liz McAnulty responded for the UKCC, noting that as the police were not going to conduct any further inquiries, and given that the UKCC had to apply a similar standard of proof to matters of fact, it would not be progressing matters any further (HCO003121).
Liz McAnulty’s letter prompted Detective Superintendent (Det Supt) Jonathon (John) James to respond on 21 February setting out the terms of the police inquiry. He highlighted the fact that the police investigation concerned the criminal offence of gross negligence manslaughter and said: “this seems to me to be very different from determining, to the same standard of proof, that nursing or medical staff have failed to deliver care to the appropriate professionally recognised standards”. Det Supt James went on to say:
“The reports previously forwarded to you were only a small part of the information gathered during the course of our investigations. In order to enable UKCC to discharge its functions as a regulatory body I have authority to share all information with you in addition to the material already supplied. I would stress that our enquiries have focused upon the potential criminal liability of individuals. I nor any other member of the enquiry team, have not, and could not, have come to an informed conclusion about the standard of care delivered by individual doctors or nurses against any recognised professional benchmark. Nevertheless, it appears that there is a prima facie case for enquiries to be commenced to establish whether or not individuals concerned in the care of patients described in the reports of Ford, Livesley and Mundy have failed to meet professional standards of care.” (HCO501396, pp1–2)
On 13 February, Det Supt James wrote to family members who had made complaints about the treatment of their loved ones while in the hospital. While stating that there would be no further criminal investigation into the deaths, Det Supt James informed family members that the reports commissioned as part of the investigation had been forwarded on to the regulatory authorities, including the UKCC, which could “Initiate further enquiries or act upon the reports as they deem appropriate”. (See, for example, HCO003912.)
The documents show that the UKCC asked the Trust for comments on Professor Ford’s report but took no other action. The Trust responded on 15 May, indicating that it would take no disciplinary action against any of the nurses named (NMC100012, p2).
Family members contacted the NMC (which had succeeded the UKCC) in 2002, expressing their concerns about the hospital:
- On 17 May, Bernard (Barney) Page made a formal written complaint about the treatment of his late mother, Eva Page, by the nurses involved. He considered that there were “several areas of grave concern” (NMC100338, p11).
- On 1 June, Marilyn Jackson made a formal complaint to the NMC about the “appalling level of care” given to her mother, Alice Wilkie, prior to her death at the hospital in August 1998. The complaint referred to the nursing staff generally and to a nurse by name (IMI000178).
- On 6 June, Ann Reeves wrote to the NMC lodging a formal complaint against the nurses involved in respect of the treatment of Mrs Reeves’s mother, Elsie Devine. Mrs Reeves stated that her mother had received treatment that was tantamount to “abuse” and that “those involved in our Mother’s care are inhumane and a poor representation of the medical profession” (NMC100338, pp7–8).
- On 19 June, Marjorie Bulbeck wrote to the NMC to register a formal complaint about the nursing care provided to her mother, Dulcie Middleton. The complaint referred to the conduct of individual nurses (albeit unnamed) and the poor standard of nursing care generally, stating that “some nurses were uncaring and had an unprofessional attitude to vulnerable helpless patients” and “lacked humanity” (NHE000584, p4). Mrs Bulbeck later wrote to the NMC naming a nurse as being responsible for the “appalling care my Mother received whilst at the Gosport War Memorial Hospital” (NMC100325, p358).
- On 22 August, Rita Carby wrote to the NMC lodging a formal complaint against the nursing staff alleging “complete negligence” on the part of the relevant nurses in the treatment of her husband, Stanley Carby (NMC100325, p372).
The NMC passed Mrs Bulbeck’s complaint on to the Trust (NHE000586, p2). The PCT referred the NMC to the report of an investigation carried out by Jane Williams, Nurse Consultant in Stroke Care. The report of the investigation, prepared by Fiona Cameron, Operational Director at the PCT, noted that the nursing documentation was inadequate and found certain concerns in relation to the treatment of Mrs Middleton but did not find evidence of any misconduct by a named nurse (NMC100325, pp363–5).
The NMC also referred the complaint from Mrs Carby to the Trust, which commissioned Professor Jean Hooper to prepare a report (DOH800992). Professor Hooper’s report concluded that, while there were discrepancies in the nursing records in terms of dates and times, she was “unable to find any specific reason through review of the notes to indicate that the nurses were negligent in their care and management of Mr Carby” (NMC100325, p377).