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Gosport Independent Panel

Chapter 8: The inquests

What happened before the inquests were opened


Following the CPS decision in December 2006 not to bring criminal proceedings, Mr Horsley’s workload meant that he did not hold a meeting with the police until 11 April 2007, when they provided a file of material (HCO002530, PCO000292PCO000324). Crucially, while this file did contain a summary of the investigation, the evidence that was produced focused solely on the ten deceased. The focus of the coronial investigation at this stage was clearly to be on these ten and no more.


One of the difficulties that the Coroner faced at the outset was that, in respect of seven of the Category 3 cases, the bodies had been cremated. Pursuant to section 8(1) of the Coroners Act 1988, a Coroner can only open an inquest into a death when the body of the deceased is lying within his district. Mr Horsley formed the view that he would need the permission of the Secretary of State to open inquests into the seven deceased who had been cremated as the bodies had been destroyed by fire. Application to the Secretary of State in this regard was made on 15 June 2007 (PCO000058).  


From the very early stages of his involvement, Mr Horsley was concerned that the inquests into the ten deaths would put considerable strain on the Portsmouth and South East Hampshire Coroner’s Office, both in terms of the financial cost of conducting the inquests and of staff resourcing issues. At a meeting with the Department of Health (DH) and the Ministry of Justice, Mr Horsley said that “the ordinary work of the jurisdiction would be very seriously affected”, and that he could not organise these inquests with his present complement of administrative staff and officers (PCO000128).


By June 2007, Mr Horsley had identified Andrew Bradley as a suitable person to undertake the inquests on his behalf (HCO002469). However, Mr Bradley was not appointed as an Assistant Deputy Coroner for South East Hampshire until April 2008, meaning he was unable to undertake any work on the inquests before then. It appears that Mr Bradley was chosen as he was the part-time Coroner for North East Hampshire, based in Basingstoke, and had recently retired from private practice as a solicitor. This meant “he would have the time to do the inquests and is familiar with the local police etc., etc.” (MOJ000010).


Shortly after writing to the Secretary of State for permission to open inquests into the seven deceased who had been cremated, Mr Horsley contacted the Ministry of Justice, indicating that he considered that a public inquiry might be preferable to an inquest (PCO000059, pp4–5).


On 21 August 2007, a meeting was held between Mr Horsley, representatives of the Ministry of Justice and DH (PCO000128). At that meeting, Mr Horsley said that while writing to Paul Harris at the Ministry of Justice, he had realised the scale of Operation Rochester. Mr Horsley stated that there were “extremely serious resource implications for the Coroner, and for the normal operation of the service in his district” (p2). There was general agreement that the inquests would prove to be a “crushing expense for the Council” (p4). In fact, in later correspondence with the Ministry of Justice, Mr Horsley confirmed that at that time he was principally concerned with the potential resource implications of holding up to 92 inquests (PCO000186).


The record of the August 2007 meeting notes that Mr Horsley also expressed his:

“… deep misgivings about handling these cases as inquests. The conduct of the doctors concerned was an issue, but so too was the management of the hospital. In his view that aspect went beyond the remit of an inquest. He also had concerns, if the inquest route were taken, about the enormous quantity of evidence and the large number of expert witnesses … He suggested that the public inquiry route would be a better way to address the public expectations. Its terms of reference could be set so as to achieve everything that inquests could.” (PCO000128, p3)


Mr Horsley was not alone in expressing the view that a public inquiry was preferable to an inquest. Karen Murray from Hampshire County Council expressed “serious concerns. The whole Hampshire budget for the normal Coroner service was some £800,000 and these ten inquests would cost at least that. The council would support the best means of exposing the facts, and believed that a public inquiry was the best way to achieve that” (PCO000128, p3). Judith Bernstein from the Ministry of Justice stated that “the coronial system was not suited to this scope of inquiry” (p3).


Colin Phillips, a DH official, said that there would be no public inquiry as the case was “old and about the actions of individuals” (PCO000128, p3). It was further pointed out that the deaths at Gosport War Memorial Hospital (‘the hospital’) did not, in the opinion of DH, “raise issues of national concern” (PCO000186). Nor would the Ministry of Justice or DH provide any funding for the inquests if they were to take place (PCO000128, p4).


Despite DH’s refusal to entertain the possibility of a public inquiry, there remained discontent. Mr Bradley wrote to the Ministry of Justice as late as January 2009, just over two months before the inquests touching the ten deaths at the hospital were due to begin, asking for reconsideration of the decision not to hold a public inquiry instead of inquests. He stated that his “work on the file causes me increasing concern because of the nature of the proceedings” (PCO000187). The concern expressed went beyond a matter of simple resources to doubts about what could be achieved through the inquest process:

“… it is quite apparent that inquests are not going to provide any of the families with the answers that they require. The remit of these inquests means that the matters of public policy with which the families are concerned cannot be addressed and taking forward ten cases to inquest means that the remaining eighty two cases that were investigated remain without answers.” (PCO000187)


Mr Bradley went on to say that the:

“… scope of the inquests will not address the overall provision of health care for the elderly at Gosport … a public inquiry would allow for a full and thorough investigation as a result of which families can maintain confidence in the system for the provision of health care and death certification.” (PCO000187, p2)


Mr Horsley also wrote to the Ministry of Justice in support of Mr Bradley’s request for reconsideration of the matter. Mr Bradley said that since the inquests had been opened, “it has become apparent that the inquest process is not going to deliver the sort of investigations and conclusions which are envisaged by the families involved”. He added: “I consider that a public inquiry into all the deaths is needed to allay public concerns about what happened and will do so in a way which the limited scope of the inquest could never do so” (PCO000186, p2).


Even the lawyers representing Portsmouth Hospitals NHS Trust (‘the Trust’) appeared to be of the view that matters should be taken forward by a public inquiry (PCO000636); that the families would not be satisfied by what could be achieved at an inquest (MRE001137); and that the Ministry of Justice had “fobbed off” the families by ordering inquests instead of a public inquiry (MRE001098).


Despite this, the pleas of both Coroners fell on deaf ears. The Ministry of Justice responded that any decision on a public inquiry was a matter for DH. DH remained of the view that “given the variety of investigations that have already been undertaken and the powers that you have to inquire into all of the circumstances leading up to the deaths, the inquests should now proceed” (PCO000185).


The organisation that was perhaps most relieved by the decision not to hold a public inquiry instead of an inquest was the Trust itself. Mr Bradley had indicated in a telephone call with the Trust’s solicitor that he had written to the Ministry of Justice requesting that the hearings should take the form of a public inquiry. The solicitor suggested to Peter Mellor, Company Secretary for the Trust, that a public inquiry would be “an administrative/PR disaster” and the NHS would not be happy with one (MRE001037).


The argument over a public inquiry would return later. At the time, following the meeting on 21 August 2007, the Ministry of Justice sent a letter to the Coroner confirming that DH made it clear “that the advice of their ministers and the Chief Medical Officer was that a public inquiry was unjustified and that any concerns would be best addressed by the inquest process” (PCO000057). The Ministry of Justice requested further information in relation to the desirability of opening inquests into the ten deceased before a decision was made to grant Mr Horsley permission to proceed (PCO000057).


The decision not to hold a public inquiry into the deaths at the hospital was a missed opportunity. As a result, the inquests into the deaths at the hospital were not able to consider in sufficient detail matters relating to the management and history of events at the hospital dating back to 1991, or the culture of proactive prescribing and end of life care more generally.


Following this decision by DH, both Mr Horsley and Mr Bradley took the view that, if the matter was not to be dealt with by way of a public inquiry, then any investigation would have to be limited in scope.


The suggestion that the deaths at the hospital did not raise “matters of national importance” was surprising.


Mr Horsley did not respond to the Ministry of Justice request for further information until 26 November 2007 – in part, it appears, because he suffered an injury to his arm (PCO000050). There then followed a further period of nearly three months before the Ministry of Justice made a decision on whether to grant permission for the inquests at all. This was despite two letters from Mr Horsley asking for a decision and highlighting the acute and public embarrassment that the delay was causing (PCO000044).


Permission was finally provided on 12 February 2008 (PCO000064). Two months later, on 11 April, Mr Bradley and Mr Horsley met to discuss how to proceed with the inquests. It was agreed that Mr Horsley would open the inquests as soon as possible. Mr Bradley was to meet Detective Superintendent (Det Supt) David Williams “to discuss witnesses, PIPs, timing, time estimate etc and the mechanics for a pre-inquest hearing”. Mr Bradley was of the opinion that the inquests would require a jury, and he hoped to have a pre-inquest hearing in June with an inquest date in October (PCO000036). The inquests were opened on 14 May 2008.


The available documents show the arguments which were made in favour of a public inquiry and the reasons given for resisting Mr Horsley’s request. The documents show little justification for the delay between the CPS decision in December 2006 and the eventual start of the pre-inquest hearings listed for 14 August 2008.