Skip to main content

Gosport Independent Panel

Volume 649: debated on Wednesday 21 November 2018

In June this year, the Gosport Independent Panel published its report into what happened at Gosport War Memorial Hospital between 1987 and 2001. It found that 456 patients died sooner than they would have done after being given powerful opioid painkillers. As many as 200 other people may have had their lives shortened, but this could not be proved because medical records were missing.

The findings in the Gosport report are truly shocking, and we must not forget that every one of those people was a son or daughter, a mother or father, a sister or brother. I reiterate the profound and unambiguous apology on behalf of the Government and the NHS for the hurt and anguish that the families who lost loved ones have endured. These were not just preventable deaths, but deaths directly caused by the actions of others. The report is a deeply troubling account of people dying at the hands of those who were trusted to care for them. I pay tribute to the courage of the victims’ families and their local MP, my hon. Friend the Member for Gosport (Caroline Dinenage), in their work for and commitment to the truth. Without their persistence, the catalogue of failures may never have come to light.

Along with the Prime Minister, I have met Bishop James Jones, who chaired the panel. He made it absolutely clear that what happened at Gosport continues to have an impact and places a terrible burden on relatives to this day. The failures were made worse because whistleblowers were not listened to, investigations fell short and lessons failed to be learnt. We must all learn the right lessons from the panel’s report and apply them across the entire system.

As Bishop Jones writes in the report, relatives felt betrayed by those in authority and were made to feel like “troublemakers” for asking legitimate questions. The report states that

“when relatives complained about the safety of patients…they were consistently let down by those in authority—both individuals and institutions. These included the senior management of the hospital, healthcare organisations, Hampshire Constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and the Nursing and Midwifery Council.”

The panel heard how nurses raised concerns as far back as 1988, but were ignored and sidelined. More than 100 families raised concerns over more than two decades, but they were ignored and patronised. Frail, elderly people were seen as problems to be managed, rather than patients to be helped. Perhaps the most harrowing part of the report is when it makes clear that if action had been taken when problems were first raised, hundreds fewer would have died at Gosport. People want to see that justice is done, policies are changed and that we learn the right lessons across the NHS. I will take each of those in turn.

First, on justice, between 1998 and 2010, Hampshire constabulary conducted three separate investigations. None of the investigations led to a prosecution. The panel criticised the police for their failings in the investigations and their failure to get to the truth. Families said that they felt police had not taken their concerns seriously enough or investigated fully. Because of Hampshire police’s failures, a different police force has been brought in. A new, external police team is now independently assessing the evidence and will decide whether to launch a full investigation. They must be allowed to complete that process and follow the evidence, so that justice is done. Much has improved in the NHS since the period covered by the panel’s report, but we cannot afford to be complacent. What happened at Gosport is both a warning and a challenge.

Let me turn to the reforms that have been made and the reforms that we plan to make. The Care Quality Commission has been established as an independent body that inspects all hospitals, GP surgeries and care homes to detect failings and identify what needs to be improved. We have set up the National Guardian’s Office to ensure that staff concerns are heard and addressed. Every NHS trust in England now has someone in place whom whistleblowers can speak to in confidence and without fear of being penalised. We have established NHS Improvement—a separate, dedicated organisation—to respond to failings and put things right, and the Healthcare Safety Investigation Branch now investigates safety breaches and uses them to learn lessons and spread best practice throughout the NHS.

Those are the reforms that the Government have already made, but we must go further, so motivated by this report we will bring forward new legislation that will compel NHS trusts to report annually on how concerns raised by staff have been addressed; and, we are working with our colleagues in the Department for Business, Energy and Industrial Strategy to see how we can strengthen protections for NHS whistleblowers, including changing the law and other options.

Next is the question of drug prescription. Central to the deaths at Gosport was the prescribing, dispensing and monitoring of controlled drugs. Since the period covered by the report, there have been significant changes in the way that controlled drugs are used and managed and these syringe drivers are no longer in use in the NHS. However, in the light of the panel’s findings, we are further reviewing how we can improve safety.

Further, from April next year, medical examiners will be introduced across England to ensure that every death is scrutinised by either a coroner or a medical examiner. Medical examiners are people bereaved families can talk to about their concerns to ensure that investigations take place when necessary, to help to detect and deter criminal activity and to promote good practice. The new system will be overseen by a new independent national medical examiner and training will take place to ensure a consistency of approach and a record of scrutiny.

The reforms that we have made since Gosport mean that staff can speak up with more confidence and that failings are identified earlier and responded to quicker. The reforms that we are making will mean greater transparency, stricter control of drugs and a full and thorough investigation of every hospital death. Taken together, they mean that warning signs about untypical patterns of death are more likely to be examined at the time, not 25 years later.

However, as well as these policy changes, there is a bigger change, too, which I turn to now. Just as with the reports into Mid Staffs and Morecambe Bay, the Gosport report will echo for years to come, and the culture change that these reports call for is as deep-rooted as it is vital. There has been a culture change within the NHS since Gosport, but the culture must change further still. One of the most important things that we learnt from the report is that we must create a culture where complaints are listened to and errors are learnt from, and that this must be embedded at every level in the NHS.

What happened at Gosport was not one individual error; it was a systemic failure to respond appropriately to terrible behaviour. To prevent that from happening again, we need to ensure that we respond appropriately to error—openly, honestly, taking concerns and complaints seriously and seeing them as an opportunity to learn and improve, not a need for cover-up and denial. I want to see a culture that starts by listening to patients and their relatives and by empowering staff to speak up. That starts with leaders creating a culture that is focused on learning not blaming—a culture that is less top-down and less hierarchical, with more autonomy for staff, and that is more open to challenge and change. We need to see better leadership at every level in the NHS to create that culture across the NHS.

Today marks an important moment. Lessons have been learned, will be learned and must be applied. The voices of the vulnerable will be heard. Those with the courage to speak up will be celebrated. Leaders must change the culture to learn from errors, and we must redouble our resolve to create a health service that will be a fitting testament to the Gosport patients and their families. I commend this statement to the House.

I thank the Secretary of State for an advance copy of his statement. I welcome the statement and the tone of his remarks, and I thank him for repeating the unambiguous and clear apology that the previous Secretary of State, the right hon. Member for South West Surrey (Mr Hunt), offered at the Dispatch Box before the summer—it is good to see the previous Secretary of State sitting on the Treasury Bench today.

We welcome the Secretary of State’s apology today. The whole House was shocked when the previous Secretary of State reported the findings of the Gosport inquiry to the House. This Secretary of State is right to remind us that everyone who lost a life was a son or daughter, a mother or father, a sister or brother. As he said, our thoughts are with the families of the 456 patients whose lives were shortened because of what happened at Gosport, and the families of the 200 others who may have suffered—whose lives may have been shortened; because of missing medical records, we will never know for sure. That lingering doubt—never knowing whether they were victims of what happened at Gosport—must be a particularly intolerable burden for those families affected.

Like the Secretary of State, I pay tribute to the victims’ families, who, as he says, have in the face of grief shown immense courage, fortitude and commitment to demand the truth. I think the whole House will pay tribute to them today. I also reiterate our gratitude to the former Bishop of Liverpool, James Jones, for his extraordinary dedication, persistence, compassion and leadership in uncovering this injustice. Finally, I applaud those hon. Members who played a central role in establishing this inquiry, not just the previous Secretary of State, but the right hon. Member for North Norfolk (Norman Lamb) and the Minister for Care, the hon. Member for Gosport (Caroline Dinenage), who in recent years has played an important role in her capacity as a constituency MP.

The Secretary of State is correct to say that lessons must be learned and applied across the whole system. We all understand that in the delivery of healthcare and the practice of medicine, sadly, tragically, things can and do sometimes go wrong, but we also understand, as Bishop Jones said in his report, that

“the handing over of a loved one to a hospital, to doctors and nurses is an act of trust”,

but that that trust was


I still believe that that betrayal was unforgivable. Patient safety must always be the priority, so when there are systemic failures, it is our duty to act, learn lessons and change policies.

I wish to respond to the Secretary of State’s announcements today. We welcome his commitment to legislation placing more transparency duties on trusts, and we will engage constructively with that legislation. Is it his intention to bring forward amendments to the Health Service Safety Investigations Bill, and if so when, or should we expect a new bill altogether? We look forward to his proposals on strengthening protection for whistleblowers, but he will know that the NHS has just spent £700,000 contesting the case of whistleblower Dr Chris Day, a junior doctor who raised safety concerns. He will also be aware of the British Medical Association survey showing that not even half of doctors feel they would have the confidence to raise concerns about safety. Moreover, he will be aware of how Dr Bawa-Garba’s case played out, with her personal reflections effectively used in evidence against her. Can he offer more details on how he will change the climate in the NHS so that clinicians feel they can speak out without being penalised?

I welcome the thrust of the Secretary of State’s remarks on medical examiners, and I agree they are a crucial reform, but can he offer us some more details? Is it still the Government’s intention that they will be employed directly by acute trusts? He will be aware that this has provoked questions about their independence. We would urge him to go further and base them in local authorities and extend their remit to primary care, nursing homes and mental health and community health trusts. If legislation is needed, we would work constructively with him.

We welcome the review into improving safety when prescribing and dispensing medicine. Clearly, one of the first questions that comes to mind when reading the Gosport report is: how were these prescriptions monitored? The Government’s own research indicates that more than 230 million medication errors take place a year, and it has been estimated that these errors and mix-ups could contribute to as many as 22,000 deaths a year, so this review is clearly urgent. Can the Secretary of State tell us whether it will be an independent review, who will lead it and when we can expect it to report?

Finally, patient safety is compromised when staff are overworked and overburdened with pressures. He will know that we have over 100,000 staff vacancies across the NHS. Some trusts are proposing closing A&E departments overnight because they do not have the staff, and some are even proposing closing chemotherapy wards because they believe that the lack of staffing means services are unsafe. How does the Secretary of State plan to recruit the staff our NHS desperately needs to provide the level of safe care patients deserve?

In conclusion, I offer to work constructively with the Secretary of State to improve patient safety across the NHS, and we support his statement today.

I appreciate the tone of the hon. Gentleman, who rightly focuses on the need to ensure that this never happens again, and I join him in thanking Bishop James Jones for his work on this and other inquiries. It was quite brilliant empathetic work. I also thank the right hon. Member for North Norfolk (Norman Lamb), for whom I have an awful lot of respect.

The core of the questions the hon. Gentleman raised, about the need to ensure that whistleblowers are listened to and that people are heard in the NHS, comes down to culture change. A whole series of policies underpins that culture change, and I will come to them, but ultimately it comes down to this: errors happen in medicine—it is a high-risk business—but what matters is behaviour, that everything is done to minimise errors and, when they are made, to learn from them, rather than try to cover them up. The culture change needs to be driven across the NHS. It has changed and improved in many areas, but there is still much more to do.

The hon. Gentleman asked whether amendments would be tabled to the Health Service Safety Investigations Bill or in separate legislation on whistleblowers. We are looking at both options. Partly it comes down to the technicalities of scope and the exact distinction and definition of the amendments, but I look forward to working with him on that legislation.

The hon. Gentleman asked why gagging clauses are still in use. I may well ask the very same question. They were deemed unacceptable by my predecessor—I join in the tributes to him—who did so much on this agenda. Gagging clauses have been unacceptable in the NHS since 2013. Trusts, which are independent, can legally use them, but I find them unacceptable, and I will do what it takes to stamp them out.

The hon. Gentleman said that too many people in the NHS feel unable to speak up. To ensure a route for this, we now have, in every single NHS trust, an individual separate from line management to whom staff can go to raise concerns. This is part of the culture change, but it is not the whole. Line management itself in every hospital should welcome challenge and concerns, because that is the way to improve practice. Challenges and concerns that are raised with managers should be deemed an opportunity to improve the service offered to patients, rather than a problem to be managed.

The hon. Gentleman also mentioned medication errors. Of course, this was not a case of medication error—it would have been far less bad had it been; it was a case of active mis-medication that led to deaths. Medication errors are an important issue, however, and we are bringing in e-prescribing across the board to allow much more accurate measurement, audit and analysis of medication.

Finally, the hon. Gentleman said that pressures often come from staff shortages. Again, that was emphatically not the concern here, and we absolutely must not muddle up the behaviour here with the issue of staff shortages. Nevertheless, I acknowledge the need for more staff in the NHS. Indeed, we are putting £20 billion into it over the next five years to make sure we have the people we need to deliver the NHS that everyone wants.

I welcome the Secretary of State’s statement and commitment to introduce legislation to compel trusts to report on how they handle staff complaints and concerns, but will he assure the House that trusts will not be penalised if they have more staff concerns raised, because it might be an indicator that they have introduced the culture change necessary for staff to feel able to come forward? Will he also clarify how rapidly we will be rolling out the very welcome introduction of medical examiners?

My hon. Friend is absolutely right that the number of complaints and concerns raised is not the material factor. A complaint that is actively welcomed and then acted on by management is merely part of the improvement process of any organisation. We should be open to them, welcome them and see them as an important part of the continuous improvement of NHS trusts, which is how many successful organisations see them. As I set out in the statement, medical examiners will be introduced from next April, but I am happy to give her more details of that whole policy.

I, too, welcome the Secretary of State’s statement and the proposals in it. As he says, these 450—possibly even 650— deaths were not accidental, but deliberate.

I welcomed the Secretary of State’s attendance at our event yesterday, when we discussed the need for a just and learning culture in the NHS. Obviously, he heard the stories that were related during the event: stories of patients who had lost their lives, and families who have ended up spending their entire lives fighting for justice or change, so they have suffered over and above their bereavement. Staff were obviously not listened to. One witness compared a whistleblower with someone reporting to the police, or a state witness, and pointed out how shocked we would be if the police tried to shut that case up. Whistleblowers should be welcomed as people giving evidence against wrongdoing or failure.

I particularly welcomed the Secretary of State’s comment about reform of the Public Interest Disclosure Act 1998, which I think needs to be replaced. I think we need legislation that gives definite protection to people who come forward. As one who has been a clinician for more than 30 years, I can tell the Secretary of State that the long trail of clinicians who have reported concerns and then had their careers ended lies there like a threat to every whistleblower who thinks of speaking up.

If patient safety and the ability of people to speak up in safety are not enshrined in the NHS, we are all under threat. I am sure that not just the hon. Member for Leicester South (Jonathan Ashworth) but Members in all parts of the House would work with the Secretary of State to reform the legislation here and inspire the culture change that is needed in the NHS itself. I certainly would.

I agree with an awful lot of what the hon. Lady has said, and I appreciate the wisdom that she brings to this issue with her clinical experience.

The need for a just culture in the NHS is very clear, and the Gosport report makes it clearer still. A just culture means that, yes, there is accountability, but the accountability is established with the intent that the system will improve and people will learn; that people can come forward with concerns rather than covering them up; and that when concerns are expressed, they are welcomed.

I am also pleased about the hon. Lady’s attitude to potential legislation. I look forward to working with her, and, indeed, learning from some of the improvements that have been made in Scotland, to try to ensure that we can get this right.

The events at Gosport are of substantial interest to my constituents in Havant and across the Solent region. I agree with the Secretary of State that lessons must be not only learned but applied. Will he confirm that ensuring patients’ safety will remain at the heart of all that the NHS does, including the development of its new 10-year plan, and will he confirm in particular that better medical records can be produced through, for instance, the use of new technologies?

Absolutely, and I pay tribute to my hon. Friend’s work. People from across the country, and certainly from across the region, were affected by this. The need for better medical records is underlined in the report. In the case of several hundred people, we do not know whether their lives were shortened or not. Of course technology has a huge part to play in this. From about 15 years ago onwards it is highly unlikely that medical records would have been lost or misplaced in this way, and therefore new technology has a role to play, but it needs to be improved so that access to those records can be made available to the right people at the right time.

I welcome the ambition in the statement for the culture change that is clearly still needed in the NHS. This is the most extraordinary scandal. The Secretary of State is right to highlight the extent to which loved ones were patronised and ignored and staff were often crushed, and how that facilitated the ongoing scandal at Gosport War Memorial Hospital. Clearly, the pursuit of justice is the most pressing priority for the relatives, given how long delayed that is, but may I specifically highlight the Secretary of State’s reference to working with the Business Secretary to establish whether reforms to the legislation are necessary? Does he agree that reformed legislation that allows staff to feel able to speak out—not just in the NHS, but in any occupation—can facilitate the very culture change that he needs so much?

Yes. I pay tribute to the right hon. Gentleman’s work, especially as a Minister in the Department, to make sure that people got to the bottom of this and that the truth was published and brought out in the way that it has been. He is right about the question of justice, but it is currently—rightly—a matter for the police, so I will go no further than that.

I strongly agree with the right hon. Gentleman that the legislative framework that we set here in Parliament leads to and underpins the culture that is critical. That is, of course, a matter for the whistleblowing legislation. There are also questions of legal liability. As the right hon. Gentleman well knows, often what patients who have been wronged—or the families of patients who have been wronged—want most of all is an apology, an explanation and a commitment that others will not be affected because the lessons will be learnt. Too often what has been offered instead is the phone number of a no-win, no-fee lawyer, and that is not the way to solve this problem.

I welcome the Secretary of State’s announcement and his plain and self-evident commitment to learning from this episode and righting the wrongs. The findings of the report are shocking and heartbreaking, and they affect some of my constituents whose families have suffered so much grief because of the life-shortening policy employed at Gosport War Memorial Hospital. Many of them still have questions many years on, about such matters as criminal investigations. I welcome the Secretary of State’s announcement that an external police team will be carrying out an investigation on whether to press charges, but can he provide some guidance on the timeline and whether the police can realistically expect justice to be done, and seen to be done, through the criminal courts?

My hon. Friend is right. The grief over the loss of a loved one whose life has been foreshortened is compounded if that is not acknowledged by the authorities, and we therefore acknowledge it once again today. As for the police investigation, the timings are of course a matter for the police themselves, who are rightly independent. The process currently under way is the reviewing of all the evidence to establish what and whether prosecutions should be brought forward. That will continue into the new year, and the police will then make a statement on the next stages of their investigation.

On 10 October, my constituent Bridget Reeves submitted a petition with more than 100,000 signatures to the Government to trigger a parliamentary debate. Today is the anniversary of her grandmother Elsie Devine’s death at Gosport War Memorial Hospital. She died after concerns had emerged from staff at the hospital.

I thank the Secretary of State for his statement and for his commitment to addressing many of the problems that have already been identified and are emerging from the various inquiries. The families want justice, among other things, but they will not get it until the outcome of the fourth police investigation—and I welcome the fact that it is being carried out by a different police authority.

I have two questions. First, will the Secretary of State meet the families face to face? Secondly, while I acknowledge his points about concerns of culture in the NHS, I am concerned about the culture in the coroner service, in relation to not just this case but others, including one that I met constituents to discuss this morning. There is a governance issue relating to when the coroner service needs investigating in the case of some inquests. Will the Secretary of State work with the Attorney General and pick up the concerns that Members expressed about a number of inquests?

The point about coroners is a matter for the Ministry of Justice, but I am pleased to see that the Under-Secretary of State for Justice, my hon. Friend the Member for Charnwood (Edward Argar) is present. He would delighted to meet the hon. Lady to take up that point—

Yes: good.

I will, of course, be happy to meet the families, but the advice of Bishop James Jones is that that will be appropriate after this stage of the police investigation. I wrote to the families to explain the position before making my statement. It is important that we go through the process properly during the police investigation to ensure that justice can be done, but I shall be more than happy to meet the families at the appropriate moment.

Order. I always listen to all of my colleagues with equal doses of respect and affection, but I am moved to observe as we approach the festive season that it would probably be a good idea for the right hon. Member for New Forest West (Sir Desmond Swayne) to send copies of his textbook on succinct questions as Christmas presents to all colleagues.

I join the cross-party support for my right hon. Friend’s statement and add my voice in commending the dedication and commitment of Bishop James Jones, who, I am pleased to say, is I think in the Chamber listening to the Government response to his report.

I am a great supporter of the National Guardian’s Office and the “freedom to speak up” guardians; in fact I am such a strong supporter that I wear its lanyard around my neck and have done ever since I was in the Health Department. But a number of people who make complaints either do not yet have sufficient confidence in these guardians or feel that their complaints are not properly addressed. There are however good examples of best practice, where some chief executives of trusts have a regular, routine meeting with guardians to make sure that complaints are brought directly to their attention. Will my right hon. Friend work with the senior leaders across the NHS and the National Guardian’s Office to ensure that best practice is used so we can give the most possible confidence to people with concerns about safety?

Yes, absolutely I am happy to do that, and I am happy to commend my hon. Friend’s lanyard, too. Ultimately culture change and having a good culture comes down to the leadership within the NHS and individual trusts. It has struck me in the four months that I have been doing this job that the trusts that have the best results in terms of outcomes for patients, waiting times and waiting lists and finances are also those that are hot on this subject; they listen to complaints and act on them, because they know that that is the way to improve their organisation. I want to see that sort of best practice right across the board.

Like colleagues, I welcome the Secretary of State’s statement. It was my constituent Gillian Mackenzie 21 years ago who was the first relative to raise concerns, and she has been battling ever since. She came to me 11 years ago and it was with pleasure that I introduced her and the other families to my colleague, my right hon. Friend the Member for North Norfolk (Norman Lamb). I am grateful for the changes in the health service that will hopefully prevent any such dreadful and shocking episode from happening again.

I must bring the Secretary of State back to the justice issue, however, as it is very important. I appreciate that it concerns a different Department, but the Secretary of State said in his statement that the police

“must be allowed to complete that process and follow the evidence, so that justice is done.”

A few weeks ago I had a constructive meeting with Assistant Chief Constable Downing, who is in charge of that. I would like a commitment from the Government that there will be sufficient funding for the full assessment, and, if it goes to investigation, sufficient funding in the budget for a proper investigation to be done so that relatives can get the justice they have been denied for so long.

Yes, of course that is the Government’s position, and I am very happy to reiterate it today. The police need to be able to follow the evidence without fear or favour.

I declare an interest as a registered nurse and someone who has worked in areas using syringe drivers and controlled drugs. I welcome the measures announced today, but may I make two further suggestions? First, there are very strict guidelines for nurses on controlling the stock of controlled drugs, and wrongdoing is picked up very quickly. There is not, however, enough training in the use, the dosage, the method and the route of controlled drugs that would give nurses confidence to speak up. Secondly, this situation could have been picked up much sooner if we had a proper IT system that shares medical notes between hospitals and doctors.

My hon. Friend is right on both points, and I am very happy to work with her on them. On the latter point, there is still much more work to do to have a system that is fully interoperable between secondary and primary care. As she says, many patients’ GPs might have picked up on the unusual patterns if they had had access to hospital notes. That now does happen in a small number of hospitals, but it is central to improving the technological capability of the NHS.

I welcome the Secretary of State’s statement and his overall approach on patient safety. We have talked a lot about the need to change the culture from one of blame to one of accountability and transparency. That is easy to say, but difficult to implement so, as well as the changes to the annual report and procedures and process changes, will there be additional training and practical support that can help embed this new culture?

Training has improved over the last couple of decades. The training programmes are independently devised for doctors by the royal colleges and are developed and implemented with the General Medical Council and the Nursing and Midwifery Council. There is still much to do to drive through the modern culture of inclusivity and bringing in ideas from all places and to remove some of the unnecessary hierarchies in the world of medicine, both within the NHS and without. I look forward to working with my hon. Friend on that.

Finally, may I end by saying that there is still work to do, not least on the judicial element, and all of us should thank Bishop James Jones for how he has handled this process and made sure that people feel that justice can be done and that the learnings can be taken?

Bill Presented

Palestinian Statehood (Recognition) Bill

Presentation and First Reading (Standing Order No. 57)

Layla Moran, supported by Richard Burden, Sir Vince Cable, Mr Alistair Carmichael, Tim Farron, Wera Hobhouse, Ben Lake, Norman Lamb, Stephen Lloyd, Caroline Lucas, Jess Phillips and Dr Philippa Whitford, presented a Bill to make provision in connection with the recognition of the State of Palestine.

Bill read the First time; to be read a Second time on Friday 8 February 2019, and to be printed (Bill 295).