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Gosport Independent Panel: Publication of Report

Volume 791: debated on Wednesday 20 June 2018


My Lords, with the permission of the House, I will repeat the Statement made earlier today in the other place by my right honourable friend the Secretary of State for Health and Social Care about the Gosport Independent Panel. The Statement is as follows:

“Mr Speaker, this morning, the Gosport Independent Panel published its report on what happened at Gosport Memorial Hospital between 1987 and 2001. Its findings can be described only as truly shocking. The panel found that, over the period, the lives of over 450 patients were shortened by clinically inappropriate use of opioid analgesics, with an additional 200 lives likely to be have been shortened if missing medical records are taken into account. The first concerns were raised by brave nurse whistleblowers in 1991, but then systematically ignored. Families first raised concerns in 1998, and they too were ignored. In short, there was a catalogue of failings by the local NHS, Hampshire Constabulary, the GMC, the NMC, the coroners and, as steward of the system, the Department of Health.

Nothing I say today will lessen the anguish and pain of families who have campaigned for 20 years for justice after the loss of a loved one, but I can at least on behalf of the Government and the NHS apologise for what happened and what they have been through. Had the establishment listened when junior NHS staff spoke out, or had the establishment listened when ordinary families raised concerns instead of treating them as ‘troublemakers’, many of those deaths would not have happened.

I also want to pay tribute to those families for their courage and determination to find the truth. As Bishop James Jones, who led the panel, says in his introduction,

‘what has to be recognised by those who head up our public institutions is how difficult it is for ordinary people to challenge the closing of ranks of those who hold power…it is a lonely place seeking answers that others wish you were not asking’.

I also thank Bishop Jones and his panel for their extremely thorough and often harrowing work. I particularly want to thank the right honourable Member for North Norfolk, who as my Minister of State in 2013 came to me and asked me to overturn the official advice he had received that there should not be an independent panel. I accepted his advice and can say today that without his campaigning in and out of office, justice would have been denied to hundreds of families.

In order to maintain trust with the families, the panel followed a ‘families first’ approach in its work, which meant that the families were shown the report before it was presented to Parliament. I too saw it for the first time only this morning, so today is an initial response and the Government will bring forward a more considered response in the autumn. That response will need to consider the answers to some very important questions. Why was the Baker report, completed in 2003, only able to be published 10 years later? The clear advice was given that it could not be published during police investigations and while inquests were being concluded, but can it be right for our system to have to wait 10 years before learning critically important lessons which could save the lives of other patients?

Likewise, why did the GMC and NMC, the regulators with responsibility for keeping the public safe from rogue practice, again take so long? The doctor principally involved was found guilty of serious professional misconduct in 2010, but why was there a 10-year delay before her actions were considered by a fitness-to-practise panel? While the incident seemed to involve one doctor in particular, why was the practice not stopped by supervising consultants or nurses, who would have known from their professional training that these doses were wrong?

Why did Hampshire Constabulary conduct investigations that the report says were,

‘limited in their depth and … range of … offences pursued’,

and why did the CPS not consider corporate liability and health and safety offences? Why did the coroner and assistant deputy coroner take nearly two years to proceed with inquests after the CPS had decided not to prosecute? Finally, more broadly, was there an institutional desire to blame the issues on one rogue doctor rather than examine systemic failings that prevented issues being picked up and dealt with quickly, driven, as this report suggests it may have been, by a desire to protect organisational reputations?

I want to reassure the public that important changes have taken place since these events which would make the catalogue of failures listed in the report less likely. These include the work of the CQC as an independent inspectorate with a strong focus on patient safety, the introduction of the duty of candour, the learning from deaths programme and the establishment of medical examiners across NHS hospitals from next April. But today’s report shows that we still need to ask ourselves searching questions as to whether we have got everything right, and we will do this as thoroughly and quickly as possible when we come back to the House with our full response.

Families will also want to know what happens next. I hope that they and honourable Members will understand the need to avoid making any statement that could prejudice the pursuit of justice. 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, in particular whether criminal charges should now be brought. 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.

My department will provide support for families from today, as the panel’s work is now concluded, and I intend to meet as many of the families as I can before we give our detailed response in the autumn. I am also delighted that Bishop James Jones has agreed to continue to provide a link to the families and lead a meeting with them in October, to allow them to understand progress on the agenda and any further processes that follow the report. I also commend the role played by the current Member for Gosport, who campaigned tirelessly for an independent inquiry and is unable to be here today because she is with affected families in Portsmouth.

For others who are reading about what happened and who have concerns that it may have affected their loved ones, we have put in place a helpline. The number is available on the Gosport Independent Panel website and the DHSC website. We are putting in place counselling provision for those affected by these tragic events and those who would find it helpful.

Let me finish by quoting again from Bishop Jones’s foreword to the report. He talks about the sense of betrayal felt by families because:

‘Handing over a loved one to a hospital, to doctors and nurses, is an act of trust and you take for granted they will always do that which is best’,

for them. Today’s report will shake that trust, but we should not allow it to cast a shadow over the remarkable dedication of the vast majority of people working incredibly hard on the NHS front line. Working with those professionals, the Government will leave no stone unturned to restore that trust. I commend this Statement to the House”.

My Lords, I thank the noble Lord for reading out the Statement. I was able to hear only a little of the media coverage in anticipation of the report this morning, but I heard one of the relatives speaking about what she had been through over the past 20 years. It was heartrending. Our thoughts, sympathies and condolences go out to the families of those 450 patients whose lives were shortened and who have campaigned for so many years to find out what happened.

We also pay tribute to the relatives for their determination, tenacity and persistence, and to the parliamentarians and others who have played their part in helping to get the panel established or supporting the relatives who have lost loved ones. I include in this the organisation, Action against Medical Accidents, which helped the families to get inquests and to press for a full inquiry, as it has done on so many of these very difficult, awful occasions.

I finally place on record our thanks to all who served on the inquiry panel and offer particular thanks for the extraordinary dedication and calm, compassionate, relentless and determined leadership yet again of the former Bishop of Liverpool, James Jones, in uncovering injustice and revealing the truth about a shameful episode in our nation’s recent history. In its own words, the panel finally,

“listened and heard the families’ concerns”.

The four key conclusions of the panel were that there was disregard for human life and a culture of shortening lives of a large number of patients; that there was an institutional regime of prescribing and administering “dangerous doses” of a hazardous combination of medication not clinically indicated or justified; that relatives were constantly let down by those in authority in the hospital when they complained; and that senior management, Hampshire Constabulary, local politicians, the coroners system, the Crown Prosecution Service, the GMC and NMC all failed to act in ways that would have better protected patients and relatives.

As the panel comments, patients’ and relatives’ interests were,

“subordinated to the reputation of the hospital and the professions involved … a large number of patients and their relatives understood that their admission to the hospital was for either rehabilitation or respite … they were, in effect, put on a terminal care pathway”.

The report is a substantial, 400-page document published only this morning and it will take some time for us all fully to absorb each detail. I welcome the Government’s commitment to coming back to the House with a full response as quickly as possible. I also welcome the setting up of a hotline and making available counselling provision to those affected and who have lost loved ones, as well as the Secretary of State’s commitment to meeting the families, with Bishop James continuing to act as a link.

Perhaps I may raise five key issues at this stage. First, can any further action be taken in respect of the 200 additional patients whose clinical notes or medical records were missing and who the panel considered to have been affected in a way similar to that of the 450 patients given opiates without appropriate clinical direction or as a result of the prescribing and administering opioids that became the norm at the hospital?

Secondly, on GMC and NMC failures in this matter, does the Minister accept that this underlines the urgent need for legislation to streamline their professional regulatory procedures and responses? In this instance, despite GMC disciplinary action against the doctor involved resulting in her being found guilty of serious professional misconduct, it did not have the authority to overturn the decision of its disciplinary panel not to strike the doctor off the register. I understand that a White Paper on regulatory matters issued by the GMC this week emphasises that, as matters stand, the GMC is operating under a legislative framework that is 35 years old and simply not fit for purpose. A Bill has been sought by this and the other professional bodies and promised by the Government, but we still have had no sight of it. Is it not now vital that such legislation is forthcoming?

Thirdly, on the key question of patient safety, in light of this inquiry, what changes have been made, or will be made, to the oversight of how medicines, particularly opiates, are dispensed in our hospitals? Is the Minister satisfied that oversight of medicines in the NHS is now tight enough to prevent incidents like this happening again? What are the wider lessons for patient safety and the need to build the safety culture in the NHS, and is additional legislation required to keep patients safe? Do the Government now regret the abolition of the patient safety agency? Do they consider that a new independent body is urgently required to pick up and take forward the PSA remit, and will the Minister promise to review this issue? Is there a need for the scope of the draft patient safety investigations Bill to be widened to reflect the learning from these tragic events?

Fourthly, there is the issue of how a proper inquiry in such appalling situations is actually started when there are ongoing police investigations and coroners’ inquests to be held. Delay is built into the system from the outset. It is a key issue that we need to find a way through.

Finally, we have all welcomed the learning from deaths programme set up to build organisational learning on the sorts of failures that we are discussing today. How will the programme assist in helping learn the lessons in this report?

We will rightly acknowledge 70 years of the NHS and the great efforts of our NHS workers every day. On this occasion, however, the system has let so many down and we must all ask why.

My Lords, I shall crave the indulgence of the House for a moment while I read out the first two points in the summary and conclusions of the report:

“In waiting patiently for the Panel’s Report, the families of those who died at Gosport War Memorial Hospital … will be asking: ‘Have you listened and heard our concerns, and has the validity of those concerns been demonstrated?’ … It is over 27 years since nurses at the hospital first voiced their concerns. It is at least 20 years since the families sought answers through proper investigation. In that time, the families have pleaded that ‘the truth must now come out’. They have witnessed from the outside many investigative processes. Some they have come to regard as ‘farce’ or ‘cover-up’. Sometimes they have discovered that experts who had found reason for concern had been ignored or disparaged. Sometimes long-awaited reports were not published”.

I commend my right honourable friend Norman Lamb for having a quiet word with the Secretary of State to ensure that this was moved forward.

This report makes for shocking reading. It hangs on a confusion of responsibilities between two organisations, the NHS and the police force, and there is a multitude of questions to be answered. I shall put only two questions to the Minister and hinge them on two points in the report. The first is paragraph 12.62. Health bodies felt prevented from taking action because police investigations were under way. The report points out:

“All concerned assumed not only that the police investigations took priority, but that they prevented any other investigations from proceeding”.

There is clearly a need to clarify lines of responsibility between the police and the NHS regulatory bodies when there are allegations of wrongdoing and systematic failings of this kind so that organisations simply do not pass the buck. Can the Minister assure me that this work will start?

Secondly, how will the Government take forward the call for action in paragraph 12.60? I welcome the Minister’s commitment to an independent inquiry in future in such circumstances to be carried out by the police force, but the report states that,

“the evidence … suggests that, faced with concerns amounting to allegations of unlawful killing in a hospital setting, there are clear difficulties for police investigation. It is not clear to the Panel how the police can best take forward such investigations, and how they are to know whose advice to seek from within the health service without compromising their enquiries. This is … significant if the problem concerns the practice on a ward where more than one member of a clinical team is involved. It is a need that calls for action across different authorities, rather than a matter for the police service in isolation”.

We cannot guarantee that something similar to this could not happen elsewhere—please God that it does not—but what action will be taken to ensure that there is not such a muddle and confusion in a resolution? What processes are either in place or being put in place within NHS settings and with police forces to make sure that this does not happen again?

I thank the noble Baronesses, Lady Wheeler and Lady Jolly, for their very perceptive questions—as ever. First, I extend my personal sympathies to the families and join my right honourable friend in expressing our apologies on behalf of the Government and the NHS for what has happened to them and their relatives. Like the noble Baronesses have done, I pay tribute to those families and all the others who have fought so tirelessly in seeking justice. As has been acknowledged, we owe a huge debt of gratitude to Bishop Jones and his panel.

The story told in this report is of a litany of failure across many institutions, which often had very closed cultures. Unfortunately, those piled on to one another across many different agencies of government, which is what created that highly unacceptable cover-up for so long. It is about getting to the bottom of that culture. Let us face it: unfortunately these circumstances are not unique. We come across this in different parts of our society all the time, and we need to get to the heart of that closed culture to lead to a culture of accountability and transparency.

The noble Baroness, Lady Wheeler, asked some specific questions, including about the 200 additional patients without notes. Clearly, further investigation is warranted because we need to substantiate that claim. It is obviously one of the work streams that will be going forward. She asked about streamlining professional regulation, given the obvious inadequacies of the GMC and NMC regulators during this process. As my right honourable friend the Secretary of State said, every part of government needs to look to itself with great honesty about what we need to do to put in place the right environment to prevent this happening again. I think we all agree on the need to move forward to streamline professional regulation. It is not something we have yet been able to do, but the tragic news we have been discussing today gives that fresh impetus. It is clearly something we will be looking at.

Patient safety is a great passion of the Secretary of State. There were changes in the oversight of medicines, particularly opioids, after the Shipman inquiry. The noble Baroness raised some good questions about whether there is a need for an independent body, or whether in the Health Safety Investigation Branch we have that body but its remit needs to be reconsidered as part of the Bill going through. I am sure that we will be doing that.

The noble Baronesses, Lady Wheeler and Lady Jolly, asked about the issues around inquiries. One of the things that has been exposed here is that there were overlapping inquiries that were impeding each other or preventing one another moving forward. Making sure that there is a clear process for how that ought to take place when someone—a family member, a staff member, the police—has raised a concern is something we have to get to the bottom of because that bureaucratic muddle was clearly at the heart of the delay and, because of the delay, more people died unnecessarily. It is not just a case of clearing things up and making them neater; it has a massive impact on harm.

The learning from deaths programme is a big step forward. It has been taken into many bits of the health service already. It is now moving into the primary care area. Trusts are already obliged to publish deaths that ought to be in the scope of mortality reviews. From next April, all non-coronial deaths will be subject to investigation by medical examiners. That is yet another part of the patient safety environment that we need to put together.

Going beyond that, there are clearly some very challenging questions that the criminal justice authorities, coroners, the Home Office, the Department of Health and Social Care and all parts of government need to ask themselves to see whether they are really doing everything they need to do to provide a safety net to make sure that when things go wrong we find out about them quickly, we stop them and we learn from them. In the next few months, as we move towards publishing a plan for what we should do next, it is imperative that all Members of this House and the other place, who have great contributions to make in this area, feel free to engage with this process and make their recommendations to it, so that when we report we have done as thorough and comprehensive a job as we possibly can so that we can prevent these tragedies happening again in future.

Does the Minister agree that it is particularly shocking that those who did not cover up—the brave staff who expressed concerns about what was happening—were ignored for so long? Does he agree that the culture of closing ranks among some medical staff should be regarded in itself as serious professional misconduct by doctors and others? Does he also agree that there should be training in the whole of the NHS which makes it easier for staff to identify the excessive use of opiates and to have action taken upon it?

The noble Lord makes two excellent suggestions. His suggestion about whether cover-ups should count as serious professional misconduct will be something the regulators will want to consider, as is better training on the use and prescription of opioids. We have made some progress in recent years. The freedom to speak up guardians are in place, and we talked about the learning from deaths programme. There is also the duty of candour. They are clearly steps forward but the panel has exposed that we are still not there yet. The suggestions the noble Lord makes are good and serious and we will want to consider them.

My Lords, I had ministerial responsibility for this area in 2002 and the beginning of 2003, which is reported in the report. First, I associate myself with the Minister’s remarks, his commendation of Bishop James and his panel and the apology that has been given. Reading this report, the question I think about is whether, if those circumstances arose now, the response would be very much different. I am not at all sure it would. First, the report shows the reluctance at local level to have what it saw as interference from the centre in causing inquiries to take place. Secondly, while the police investigations were going on the other inquiries felt they could do nothing, as the noble Baroness, Lady Jolly, said. Thirdly, once the police investigation had been completed and the decision that no prosecutions would take place had been taken, there was an agonised debate within the coronial system about whether inquests would be appropriate. The real issue seemed to be resources. The local coroner’s office did not feel that it had the resources to conduct the inquests and if it did so it would undermine the rest of its important work. In the work now being undertaken, will a real effort be made to grip the issue of the deadening impact of police investigations in stopping us learning lessons immediately? Is the Minister confident that the changes in the coronial system will prevent the kind of unseemly debate that prevented inquests taking place for some time occurring in future?

I thank the noble Lord for associating himself with that apology. He asked the right question. It was very well put. If the circumstances arose now, would the response be different? I think there is reason to believe it would be, for the reason I have set out—the improvements that successive Governments have made on patient safety—but we should not be complacent. We cannot assume that those things are enough. I hope they are an improvement. We believe they are an improvement, but we need to ask ourselves that very difficult question about whether they would be enough. That is what we will be doing through this process.

Resources are one of the issues. We need to make sure not only that there is clarity about the circumstances under which the different bodies can carry out inquiries without impinging upon inquiries by other bodies, but that they feel that they are capable of doing so. That is one of the things we are going to need to investigate.

My Lords, I declare an interest as my wife is a lead clinician in the office of the Parliamentary and Health Service Ombudsman. My friend the right reverend Prelate the Bishop of Portsmouth cannot be in his place today as he is in his cathedral church with the families of those whose loved ones were patients at Gosport War Memorial Hospital, as they properly received the report prior to it being laid before Parliament. On his behalf, and sharing his profound concern and with some anger as a vicar and archdeacon in that area at that time, I politely remind the Minister of the evidence of disregard for human life, a culture of deliberately shortening life, and a regime of systematic overuse of opioids and of the way in which those raising concerns were treated as troublemakers. The Statement repeated by the Minister raises many questions. My questions and the questions of the right reverend Prelate the Bishop of Portsmouth are simple pastoral questions: how will the Government now guarantee the families the support they deserve? How and when will the Government act on the wider issues the report raises?

I thank the right reverend Prelate for his comments and for conveying those of his colleague, the right reverend Prelate the Bishop of Portsmouth. It is absolutely right that he is where he is today, ministering to that group of deeply affected people.

The facts as he set them out, and as are set out in the Statement, are truly shocking: hundreds of lives prematurely shortened because of these practices; institutional behaviour led by an individual but with others being complicit in it; cover-ups; whistleblowers being discouraged; and so on. It is hard to imagine a worse scenario. What the panel and Bishop James Jones have exposed through working so closely with families is the extent of the behaviour and the poor practice that went on.

The question now is, quite rightly, what we should do about it, and the right reverend Prelate quite rightly takes the pastoral position. There is counselling on offer and a helpline for those who think that their families may have been affected—there may be yet more people who come forward. There is also a commitment from the Secretary of State, and indeed all Ministers, to meet families to provide them with the support and information that they may need. There is an intention to meet those families at an event convened by Bishop Jones in October, and the panel secretariat is setting up specific conversations between the advisory clinicians on the board and individual families. One of the needs for counselling, sadly, will be after those conversations, when the truth about specific cases comes out—which is why it is about providing counselling not just today but on an ongoing basis. I can give the right reverend Prelate a commitment from the department that we will provide that for as long as necessary.

My Lords, this tragedy has similarity to Shipman and Stafford Hospital. Does the Minister agree that there should be a far better and quick complaints procedure? This has been needed for years. Nurses should feel free and safe to bring up matters of worry concerning their seniors and colleagues, and relatives should have help to complain and be listened to.

I completely agree with the noble Baroness. Clearly, improvements have been made—freedom to speak up guardians came out of the Francis review into the Mid Staffs tragedy—but I reiterate the point that I made earlier: we cannot be complacent and just assume that what exists now is up to the task, as the noble Lord, Lord Hunt, said, of guaranteeing that this will not happen again. Looking at complaints procedures, protections for whistleblowing and so on will be part of the investigations that we make.

My Lords, the events at the Gosport War Memorial Hospital all those years ago are indeed shocking, but will the Minister consider that they are perhaps a symptom of the fact that we do not have an assumption in end-of-life care that patients’ wishes must be respected? One aspect of this, perhaps slightly removed from Gosport but nevertheless relevant, is that, if people are terminally ill and enduring unbearable suffering but are mentally competent, they have no way of ensuring that they, the patients, can take control and decide when they have suffered enough. In this culture of paternalism—and this really does apply to Gosport—doctors take matters into their own hands and, in a situation such as that in Gosport, paternalistic decision-making by doctors can become extremely dangerous. Does the Minister agree that we need to bring to an end paternalistic decision-making by doctors without reference to patients’ wishes, particularly in end-of-life care?

Giving patients and of course their families much more control over the circumstances in which their lives end is clearly the right thing to do. Some very good practice has been going on—for example, Coordinate My Care across London makes sure that somewhere between 70% and 80% of people who would prefer to die at home are able to do so, as opposed to in hospital. However, it is important to emphasise that in this case by and large we are not talking about palliative care; only a small number of the people concerned whose lives were shortened were in a position where they were, in an objective sense, near end of life. Many were in after a fall, a hip replacement or something else from which they could easily have recovered and lived for many more years. That is the tragic fact. So, while I agree with the noble Baroness, it is important that we do not view the tragedy just in those terms; unfortunately, it is much broader.

My Lords, like others, I was very moved by Bishop James Jones’s foreword and the way that, as the noble Baroness, Lady Jolly, put it, the panel thought to listen to and heed the concerns of those who have been aggrieved. I have been impressed by the methodology, I suppose, of the independent panel and the way it has done exactly as the Minister says: seek to work closely with the families and, so far as I understand, build its terms of reference from the particular concerns of the families, the aggrieved and the victims—the sort of questions they are wanting to ask. Have the Government made any assessment of whether independent panels are more effective than judge-led inquiries at not only excavating the truth in historic cases but, in so doing, thereby attending to the trauma of the bereaved?

The right reverend Prelate makes a very incisive point about not only the personal qualities of Bishop James Jones in chairing this panel, with the great compassion, understanding and patience that he has displayed, as indeed has the panel, but about the methodology, as the right reverend Prelate put it, which has been non-confrontational, independent and family-focused. Unfortunately, we grapple with these problems across government from time to time, and this methodology gives us a new way of doing things. It will not be appropriate in every circumstance—something smaller or swifter might be required; equally, it might be something that requires a judicial element—but it gives us a different way of doing things that provides a very sympathetic and compassionate way of listening to families and a way to get closer to the truth.