The new Dr Death? Opioid-mad doctor killed 456 patients
Now further investigations will try to work out what her motives were
An English GP oversaw an “institutionalised practice of shortening lives” that killed 456 patients at Gosport War Memorial Hospital, an inquiry has concluded as it called for police to investigate.
Up to 200 further patients might have died as a result of medical staff “administering opioids without medical justification”, but records were missing in those cases, a report has found.
Dr Jane Barton, 69, was “responsible for the practice of prescribing which prevailed on the wards” at the scandal-hit Hampshire hospital, the inquiry concluded.
The panel cannot “ascribe criminal or civil liability”, but the panel called on Secretary of State for Health Jeremy Hunt, the Home Secretary, Attorney General, Hampshire Police and “the relevant investigative authorities” to “recognise the significance of what is revealed about the circumstances of deaths at the hospital and act accordingly”.
Hampshire Police chief constable Olivia Pinkney said the force would now study the report and “assess any new information” with the Crown Prosecution Service (CPS) “in order to decide the next steps”. The CPS had previously ruled there was insufficient evidence for gross negligence manslaughter charges.
Prime Minister Theresa May described the Gosport scandal as “deeply troubling” and apologised to families from the time it took to get answers.
The panel, led by former bishop of Liverpool James Jones, criticised nurses for failing to “challenge prescribing” and for “suboptimal care”.
The report said “families were failed” and there were successive failures by authorities, including the healthcare authorities and police to recognise what was happening and to “act to put it right”.
Barton has been accused of prescribing deadly doses of diamorphine – a powerful opiate painkiller – to patients when she worked at the Hampshire hospital.
Established to address concerns about the deaths of elderly patients, the inquiry’s work included looking at 833 death certificates signed by Barton.
Between 1998 and 2000 there was a “disregard for human life and a culture of shortening the lives of a large number of patients”, the report found.
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 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 Barton’s manager, Dr Althea Lord, and the chief executive of the hospital’s trust, Max Millett, as suspects.
Whistleblowers who 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 the need for inquiries and made clear he supported the hospital.
Police to study report
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.”
Gosport MP: Report ‘much worse’ than expected
Caroline Dinenage, Conservative MP for Gosport, said: “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.
“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 heartbreaking.”
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.”
Grant said: “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.
“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.”
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.
Claims police did not take concerns seriously
Liberal Democrat MP Stephen Lloyd, whose constituent, Gillian McKenzie, was the first to go to Hampshire Police in 1998 with concerns over the death of her mother, said lives might have been saved if she had been taken more seriously.
“If the police had taken her seriously, if the senior managers at the hospital had taken her seriously earlier, bluntly it appears that lives would have been saved.
“That is a shocking, shocking indictment of this entire process.”
Lloyd criticised the investigations carried out by the police and NHS, adding: “We finish finally with the GMC many years later finding that Barton did overuse opiates and they didn’t even debar her.”
“I think it has been an absolute travesty for 20 years,” he said.
– © The Daily Telegraph