Gosport hospital: Dr Jane Barton implicated in deaths of 656 patients, as report urges police to act

A hospital GP presided over an "institutionalised regime" which saw more than 600 patients have their lives cut short after they were prescribed powerful painkillers without medical justification, a report found.

Dr Jane Barton was held responsible for policies which led to the deaths of 656 patients who died at Gosport War Memorial Hospital while she worked there between 1988 and 2000. 

The report said that there was "disregard for human life" and and it told how patients who were viewed as a "nuisance" were given drugs on syringe drivers which killed them within days.

Families of the dead urged the authorities to prosecute as Health Secretary Jeremy Hunt said the police and CPS would “carefully examine” whether new charges should be brought.

Charles Farthing, the step-son of Arthur “Brian” Cunningham, 79, who suffered from Parkinson’s Disease and dementia, said: "I’d like to see some action. Barton was utterly reckless in her prescribing, utterly reckless. 

"She gave the nurses free licence to deal with these patients as they wished. If a nurse didn’t like you, you were a goner." 

Gillian Wilson, 73, who lost her husband Robert Wilson, 74, who was meant to be rehabilitating in Gosport after suffering a broken arm in 1998, said he was "immediately placed on a course of morphine and began to deteriorate. He was sedated, despite being no trouble to anyone."

She said: “Patient after patient after patient was put in diamorphine to shut them up. It really is shocking.”

Gillian Mackenzie, 84, who was the first to complain to police in 1998 and has campaigned tirelessly for justice for her mother Gladys Richards, said: “It is not finished. I am not settling for corporate manslaughter, I have always said that this is a case for gross negligent manslaughter."

The report also criticises Hampshire Constabulary, the GMC, and Sir Peter Viggers, the Gosport MP at the time of the deaths, for their failings.

The report drew parallels with the case of Harold Shipman, the Manchester GP who was found by an inquiry to have killed 250 people, and with Beverley Allitt, the Lincolnshire nurse who killed four children in the 1960s. 

The figures place the hospital among the worst scandals in NHS history, alongside the Mid-Staffordshire crisis, in which poor care at Stafford hospital was found to have led to excess patient deaths. 

Concerns were first raised in 1991 by hospital whistleblowers who said strong opioids such as diamorphine were being inappropriately prescribed. 

Anita Tubbritt, a staff nurse at the hospital, along with several nursing colleagues, raised concerns with hospital management but they were dismissed as “a small group of night staff who are ‘making waves’”.

Despite three police investigations Dr Barton was allowed to continue practicing until she retired in 2011, shortly after a GMC hearing found her guilty of serious professional misconduct, but failed to remove her from the medical register.

The report revealed how deaths in the hospital more than doubled between 1991 and 1998, with deaths ascribed to bronchopneumonia rising more than nine-fold between 1992 and 1994, which the panel suggests was a cause frequently listed for patients who had been inappropriately given the painkillers. 

Dr Barton joined the wards, Dryad and Daedalus in 1988, shortly before deaths began to rise. It was later nicknamed "Dead Loss" by staff.

Gillian Mackenzie, 84, whose mother Gladys Richards died at the hospital

Many of the prescriptions for fentanyl and diamorphine were not necessary as patients, some of whom were in hospital for minor ailments such as arthritis or for respite care, were not in pain or considered to be dying.

The drugs are only supposed to be prescribed as a last resort for patients who are not responding to other painkillers and if the family gives their permission.

But in many cases family members were not given enough information about their relative's condition and the drugs were used for patients who were not in severe pain. 

Dr Barton signed them off with notes saying she was "happy for nursing staff to confirm death".

Of the patients admitted to the wards between 1987 and 2001, the period the report covers and for whom there are records, 40 per cent were inappropriately given the drugs, the panel found. 

The report criticised hospital administration and Hampshire Constabulary for failing to act when alerted to the issues by whistleblowing staff. 

The GMC acted with a “lack of candour” after family members discovered that Dr Barton’s brother Professor Bulstrode, had been on the GMC council until October 2008.

The report also details how Sir Peter Viggers, then the local MP, questioned the need for inquiries into what happened at the hospital, and two managers who dealt with the initial reports were suspended a decade later having been allowed to rise to chief executive level. 

In one case, a nursing auxiliary told the police that she and another member of staff had discussed an elderly man who was considered “a difficult patient”, concluding that if he wasn’t careful he would “talk himself onto a syringe driver”.

Pauline Spilka also told officers that in another case an elderly cancer patient who was “always making demands and was considered a nuisance” was put onto a driver, fell unconscious and died within four or five days. 

Theresa May

Giving evidence to the fitness to practise panel in 2009, Dr Barton admitted that patients were given potent opioid drugs such as fentanyl when they weren’t in physical pain.

Asked about the case of Elsie Devine, an 88-year-old woman admitted for rehabilitation who was given a fentanyl patch followed by a syringe driver containing diamorphine, Dr Barton said she was “not [in] physical pain but not happy, not comfortable, not easy to look after”. 

Speaking in the House of Commons, health secretary Jeremy Hunt said the police and CPS would "carefully examine the new material in the report before determining their next steps and in particular whether criminal charges should now be brought.”

Caroline Dinenage, Conservative MP for Gosport, told the BBC that the report was "utterly chilling". 

A spokesman for the CPS said: “We will consider the content of the report and will take any appropriate steps as required.”

Prime Minister Theresa May also told MPs at Prime Minister's Questions that politicians needed to address the issue of public sector bodies "closing ranks", adding: "I'm sorry that it took so long for the families to get the answers from the NHS."

Video: Inquiry chairman Rt Rev Jones delivers verdict

It also uncovered "an institutionalised regime of prescribing and administering ‘dangerous doses’ of a hazardous combination of medication not clinically indicated or justified".

The prosecution of Harold Shipman, the mass-murderer GP, “cast a long shadow” which meant police considered if Dr Barton could be another Shipman and only looked at whether she was guilty of unlawful killing, instead of pursuing a wider investigation.

It found that police also missed chances to treat Dr Barton’s managers, Dr Althea Lord, and the chief executive of the Trust, Max Millett, as suspects.

The report concludes: "The panel found evidence of opioid use without appropriate clinical indication in 456 patients. The panel concludes that, taking into account missing records, there were probably at least another 200 patients similarly affected but whose clinical notes were not found.

"The panel's analysis therefore demonstrates that the lives of over 450 people were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital, and that probably at least another 200 patients were similarly affected."

Hospital management, Hampshire Police, the Crown Prosecution Service (CPS), General Medical Council (GMC) and Nursing and Midwifery Council (NMC) "all failed to act in ways that would have better protected patients and relatives", the panel said.

Whistleblowers were ignored and 'ostracised'

Patients and relatives were "powerless in their relationship with professional staff" and families were "consistently let down by those in authority".

Nurses Anita Tubbritt and Sylvia Griffin raised concerns 27 years ago in February 1991 about prescribing practices but these were not acted on by the hospital. A number of other nurses raised concerns about diamorphine between then and January 1992. 

The report said the hospital “could have rectified the practice” after receiving the alerts but “chose not to do so”, which led to further deaths. The nurses who blew the whistle felt “ostracised” at work as a result.

It also criticises Sir Peter Viggers, former MP for the area, who the panel said repeatedly played down what had happened, questioned thampshire he need for inquiries and made clear he supported the hospital.

Key findings of Gosport hospital opiods scandal

Here are the key findings of the Gosport Independent Panel:

• A pattern of concerning opioid prescribing at Gosport War Memorial Hospital appears to have started in 1989 and ended in 2000. Nurses first raised concerns in 1991 but the warnings were "unheeded".

• Evidence was found of opioid use "without appropriate clinical indication" in 456 patients.

• Taking into account missing records, at least another 200 patients were "probably" also affected.

• There was a "disregard for human life and a culture of shortening the lives of a large number of patients".

• There was an "institutionalised regime" of prescribing and administering "dangerous doses" of drugs without medical justification.

• Over a 12-year period, clinical assistant Dr Jane Barton, was responsible for prescribing.

• Nurses had the responsibility to challenge prescribing, but continued to administer the drugs.

• Consultants were not involved in treating patients, but were aware of how drugs were being prescribed and "did not intervene to stop the practice".

• Patients and relatives were "powerless" in their relationship with professional staff.

• When relatives complained about the safety of patients and appropriateness of their care they were "consistently let down" by individuals and authorities.

• The senior management of the hospital, healthcare organisations, Hampshire Police, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and

• Te Nursing and Midwifery Council "all failed to act in ways that would have better protected patients and relatives".

Tears as emotional relatives hear findings

Former bishop of Liverpool the Rt Rev James Jones told a Press conference in Portsmouth that the families were "enormously appreciative of what the report has said".

He said: "Their reaction was, understandably, emotional and I think the way they reacted showed them just how much they had carried inside themselves over 20 years or so.

"If I can quote anonymously one of the families, as saying to me, that it was such a relief to hear what they had thought for so long and been dismissed, to hear their narrative understood and repeated by a panel that had done such detailed research into the documents."

The Rt Rev Jones said there had been "lots of tears" and "grieving" when families were presented with the findings of the report on Wednesday morning.

He said the report did not explore why the practice of prescribing might have taken place at the hospital.

"Questions about motive are beyond the terms of reference for the panel, but those are questions that will need to be prosecuted," he said.

Kate Blackwell QC, who served on the panel, said: "One family member... said that in fact for her, this was the beginning.

"Twenty years or so too late but eventually, they were being recognised and the fault of the hospital was being recognised.

"And they were confident that today's report is the start of the process that should have taken place a long time ago."

Police to study report with CPS

Olivia Pinkney, chief constable of Hampshire Police, said: "Today is about the relatives of those who died at Gosport War Memorial Hospital and their opportunity to obtain a better understanding of what happened to their loved ones.

"The report that has been published by the Gosport Independent Panel examines the concerns raised by families over a number of years about the initial care of relatives at Gosport War Memorial Hospital and the subsequent investigations by a number of agencies into their deaths.

"Hampshire Constabulary carried out three police investigations between 1998 and 2006. This involved detailed professional assessment by a number of independent medical experts and the evidence was presented to the Crown Prosecution Service and Treasury counsel, which concluded that the evidential test for prosecution as set out in the Code for Crown Prosecutors was not met.

"We have co-operated fully with the panel's enquiries and shared with them more than 25,000 documents containing 100,000 pages of information.

"Now that the report has been published and shared with us, we will take the time to read its findings carefully. We will assess any new information contained within the report in conjunction with our partners in health and the Crown Prosecution Service in order to decide the next steps."

PM's apology for 'tragic' events at Gosport

Mrs May told MPs at Prime Minister's Questions: "The events at Gosport Memorial Hospital were tragic, they are deeply troubling and they brought unimaginable heartache to the families concerned.

"But they are a matter of which we should be concerned across this house."

She said that politicians needed to address the issue of public sector bodies "closing ranks", adding: "I'm sorry that it took so long for the families to get the answers from the NHS."

Jeremy Hunt suggests different police force should investigate

Health Secretary Jeremy Hunt told MPs that police and the Crown Prosecution  Service would examine material in the Gosport Independent Panel's report to consider their next steps and "whether criminal charges should now be  brought".  

Mr Hunt told MPs: "The police, working with the CPS and clinicians as necessary, will now carefully examine the new material in the report before determining their next steps and in particular whether criminal charges should now be brought."

Video: Health Secretary addresses Commons

He added: "In my own mind I am clear that any further action by the relevant criminal justice and health authorities must be thorough, transparent and independent of any organisation that may have an institutional vested interest in the outcome.

"For that reason, Hampshire Constabulary will want to consider carefully whether further police investigations should be undertaken by another police force."

Shadow health secretary Jonathan Ashworth said the deaths at Gosport hospital represented "a shameful episode in our nation's recent history".

Gosport MP: Report 'much worse' than feared

Caroline Dinenage, Conservative MP for Gosport, told the BBC: "The report is so much worse than any of us involved in this could have anticipated.

"It talks about shortening lives, the disregard for human life and it talks about families who thought their loved ones were there for respite and rehabilitation, and finding out they were on a terminal care pathway.

"Worryingly, it talks not only of a failure of care and the over-prescribing of opiates, but also failures in the investigation.

"So many people blew the whistle on this and so many families raised the alarm, and there was a failure to investigate by a number of a different authorities."

The MP called upon the authorities to look carefully at the findings.

"Everybody needs to look at this document and go through it with a fine toothcomb as there are so many unanswered questions," she said.

"The Crown Prosecution Service needs to look at it, Hampshire Police needs to look at it and the Government needs to look at it, not just the Department of Health, but the Home Office and the Ministry of Justice."

She added: "There are so many unanswered questions here and the families have waited so many years, and their questions deserve to be answered.

"I became an MP in 2010 and families came to see me. It has taken all this time to get to the truth and I cannot begin to imagine what the families are going through reading this report. It is utterly heart breaking."

Liberal Democract MP Norman Lamb, who announced the launch of the inquiry as care minister in 2014, said: "The findings are shocking and devastating in equal measure - both in terms of the 456 patients who had opioids prescribed inappropriately, but also the disgraceful closing of ranks to stop families from getting to the truth.

"Never again must we allow a situation to develop where ordinary people are left in the dark, ignored and not listened to. We must ensure that there is some mechanism to guarantee that whenever allegations of wrongdoing are raised by people, they are listened to and their concerns are investigated thoroughly.

"I will be asking to meet with the Prime Minister, together with those families affected, to discuss the implications of this report."

Guilty of misconduct - but no criminal charges

Inquests in 2009 and 2013 into 11 of the deaths ruled that medication prescribed by Dr Jane Barton had contributed to six patients dying.

She was found guilty of "multiple instances of serious professional misconduct" by the General Medical Council in 2010, but was not struck off and soon retired.

Much of the evidence at the fitness to practise panel concerned her "brusque, unfriendly and indifferent" manner, her "intransigence and worrying lack of insight" into the effects of her actions and her inability to "recognise the limits of her professional competence".

After the General Medical Council findings, the Crown Prosecution Service announced that there was insufficient evidence for a prosecution on charges of gross negligence manslaughter.

Patients' families: 'We want justice served'

Cindy Grant's father, Stanley Carby, died at the hospital in 1999 after being admitted for rehabilitation following a stroke.

She said: "I think there is somebody that needs to be prosecuted for what's gone on there."

Ms Grant told BBC Radio 4's Today programme: "We want justice to be served because these families' lives were taken - mums, dads, grandads, grandmas.

"We all know what went on at that hospital. We want justice served."

Lawyer calls for full investigation

Suzanne White, head of clinical negligence at Leigh Day and patient safety campaigner, said: "We were forewarned about the extent of the numbers involved in this inquiry, however nothing could have prepared us for the extent in which all these institutions have let patients down so badly. This is a terrible day for those who care greatly about patient safety.

"The panel's findings that over 450 people died, and another 200 could have been similarly affected through an institutionalised practice of prescribing unnecessary painkillers, must bring real change across the NHS so that nothing like this could ever happen again. There can be no culture of 'omerta' in the NHS.

"Despite the repeated warning signs of the initial investigation in 2003 and long-standing concerns raised by families and even staff, these appear to have been ignored.

Ms White added: "It should be remembered that many of those who died at Gosport had many happy months, years or even decades denied to them through the actions of individuals involved who must now face a full investigation.

"These cases date back to the late 1980s and I cannot imagine the distress and pain the families have had to endure for so long before they have finally had some answers about the awful circumstances of their loved one's death."

Timeline: How Gosport scandal unfolded

A separate review into deaths at the hospital, led by Professor Richard Baker, found "almost routine use of opiates" for elderly patients had "almost certainly shortened the lives of some".

It could not be published in full until 2013, 10 years after it was completed, while inquests were held and due to a police investigation. Here is how the Gosport scandal has unfolded.

GMC chief: Gosport treatment 'simply unacceptable'

Charlie Massey, chief executive of the General Medical Council, said: "Our thoughts are with the families of those who lost their loved ones following simply unacceptable treatment at Gosport War Memorial Hospital.

"Patients and their families were clearly let down by the system, and that is not good enough. This has been an extremely difficult and protracted process for each family involved.

"We welcome the work that Bishop James Jones and his panel carried out to oversee the maximum possible disclosure of information around the care of patients at the hospital over two decades.

"We will be studying the report carefully to identify learning points. We are committed to taking any further action necessary in light of information revealed by this report."