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Gosport Independent Panel

Volume 794: debated on Thursday 22 November 2018


My Lords, with permission I will repeat an Oral Statement made by my right honourable friend the Secretary of State for Health and Social Care on the Government’s response to the report of the Gosport independent panel. The Statement is as follows:

“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, or 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. It is a deeply troubling account of people dying at the hands of those who were trusted to care. I pay tribute to the courage of the victims’ families and their local MP, the Member for Gosport, and 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 says:

‘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 or sidelined. More than 100 families raised concerns over more than two decades, but 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 that which makes it clear that, if actions 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 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. It 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.

I turn to the reforms that have been made and the reforms we plan to make. First, the Care Quality Commission has been established, an independent body that inspects all hospitals, GP surgeries and care homes to detect failings and identify what needs to be improved. Next, we have set up the National Guardian’s Office to ensure 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.

These are the reforms that the Government have already made, but we must go further. 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 syringe drivers are no longer in use in the NHS. However, in the light of the panel’s findings, we are 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 whom 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 system will be overseen by a new, independent national medical examiner and training will take place to ensure consistency of approach and a record of scrutiny.

The reforms we have made since Gosport mean that staff can speak up with more confidence and that failings are identified earlier and responded to more quickly. The reforms 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, which I turn to now. Just as with the reports into Mid Staffordshire 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 we have learnt from the report is that we must create a culture where complaints are listened to and errors are learned from, and that this is 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 happening again, we need to ensure that we respond appropriately to error—openly, honestly, taking concerns and complaints seriously, 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 hierarchical, with more autonomy for staff, and which is more open to challenge and change. We need to see better leadership at every level 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 is a fitting testament to the Gosport patients and their families. I commend this Statement to the House”.

My Lords, that concludes the Statement.

My Lords, I thank the Minister for reading out the Statement updating the House on government actions since this appalling tragedy was reported to the House in June. As the Statement says, the Gosport report was “truly shocking”, and once again our thoughts, sympathies and condolences go out to the families of the 456 patients whose lives were shortened. Those families campaigned for so many years to find out what happened. We also again pay tribute to these relatives for their courage, tenacity and persistence in seeking the truth, and to the panel, with particular thanks for the calm and compassionate leadership of the chair, Bishop James Jones, for its unstinting work in uncovering the injustice and for listening to and hearing the families’ concerns.

It is important to remind ourselves of the panel’s conclusions. First, there was a disregard for human life and a culture of shortening the lives of a large number of elderly patients. Secondly, there was an institutional regime of prescribing and administering “dangerous doses” of a hazardous combination of medication not clinically indicated or justified. Thirdly, relatives were constantly let down by those in authority in the hospital when they complained. Fourthly, senior management, the local constabulary and politicians, the coroner system, the CPS, the GMC and the NMC all failed to act in ways that would have better protected patients and relatives.

We welcome the commitment to strengthen protections for whistleblowers and for new legislation to compel NHS trusts to report annually on how concerns raised by staff have been addressed. Has a detailed programme of work for this been drawn up? When does the Minister envisage that legislation on these new powers will be introduced? However, much of the Statement today is about work in progress on the actions and measures that were announced when the report was published, and it is important that we receive regular updates in the future. In his June Statement, the Minister referred to the introduction next April of medical examiners to ensure that every death is scrutinised by either a coroner or a medical examiner, and yesterday’s Statement repeats this commitment. Can the Minister advise the House on progress on this? If they are to be employed by acute trusts, how will their independence be maintained and how will they link into the mortality reviews and the Learning from Deaths guidance? Has consideration been given to basing them in local authorities so that their remit can be extended to primary care, nursing homes and mental health and community trusts? What additional resources are being provided to fund these new posts?

When the report was published, the House welcomed the urgent establishment of a hotline and of counselling being made available to all those who had lost loved ones and were affected. Are these important provisions still available and will they continue to be provided? What further support is being provided? Also, in addition to the 456 patients given opiates without appropriate prescribing or as a result of the prescribing practices at the hospital, sadly, 200 more patients were referred to in the report whose clinical notes or medical records had gone missing. The panel considered that these patients had been similarly affected. What progress has been made by the workstream set up to further investigate this appalling situation? How many more cases have been substantiated as a result of this?

On the question of oversight of the use of opiates in the NHS, is the Minister satisfied that it is now tight enough to prevent incidents such as this happening again? We welcome the promise of a further review on how patient safety can be improved when prescribing and dispensing medicine, aimed at detecting inappropriate prescribing. Can the Minister give us further details of how this review is to be conducted, including the full remit and timescales?

In June, the Minister also promised a “fresh impetus” to moving forward on the need to streamline professional regulation following the report’s condemnation of the inadequacies of the GMC and NMC regulators who failed to act in ways that would have better protected patients and relatives. What progress has been made on this work?

Finally, we come back to the key issue of patient safety and the need to build a patient safety culture in the NHS. Does the Minister consider that additional legislation is needed to keep patients safe? Is a new independent body now required to pick up and take forward the remit of the former Patient Safety Agency, so unwisely abolished by the Government?

The Statement ends by underlining the cultural change that needs to be driven across the NHS to achieve openness, transparency and learning rather than blame and the cover-up of mistakes and incidents, and of course we agree with that. For all the awfulness of its findings, the Gosport panel report has managed to ensure that the carers and relatives of loved ones and staff have been listened to and heard. We on these Benches pledge our full support for the measures which will ensure that what happened at Gosport never happens again.

My Lords, I join the noble Baroness, Lady Wheeler, in thanking the Minister for an update of this situation and I too pay tribute to the relatives and the whistleblowers in this awful scandal. I am sure that many noble Lords will remember how the Shipman scandal absolutely rocked the NHS back in the late 1990s. The learning which came out of that was meant to incorporate right across the NHS robust clinical governance structures. It is really quite ironic that the things which were put in place to deal with the Shipman case seem to have fallen apart completely as regards the particular issue of Gosport.

Whistleblowers need to be confident that there will be no danger of their being bullied. I am sure that other noble Lords will have had NHS employees ask to talk to them about whistleblowing issues. One of the saddest days I can remember was when I was sitting in the Royal Gallery talking to a very senior manager in an NHS trust who was trying to raise his concerns. In the end he resigned because he felt that he had been bullied into doing so. He was going to take his expertise elsewhere. There is learning that should come from that.

I welcome the Freedom to Speak Up initiative and the work from the National Guardian’s Office. What progress has been made in embedding the operation of that scheme? If it is still in train, when might it be embedded? What consideration has been given to a similar scheme for whistleblowers who work in the care sector? This has got the NHS sorted but, at the moment, there is no way that care workers who work in care homes or other care establishments can effectively blow the whistle.

I am grateful to both noble Baronesses for their comments. I join them in expressing both my sympathy for the families of those affected and my admiration for and gratitude to Bishop Jones and his panel.

The noble Baroness, Lady Wheeler, asked a number of questions to which I will attempt to respond. First, she was right to reiterate the shocking nature of the panel’s findings and the systemic problems that were found. The noble Baroness, Lady Jolly, talked about the Shipman case. Part of the problem here is that, in some senses, people were alert for a Shipman-type event but not for a different type of event; it is almost always the case that when things go wrong, they go wrong in a different way. That is why we need a different approach from simply focusing on the actions of one person.

The noble Baroness, Lady Wheeler, asked about legislation. We are considering whether the right route would be through the draft health service safety investigations Bill, which is coming through Parliament at the moment, or other routes. Her request for regular updates is a good one; by the time we next report on such an update, I will be able to update her on the type of legislation we intend to use. I am grateful to both noble Baronesses for offering to support us through that process.

Clearly, the medical examiners’ policy is critical to making sure that we do not suffer these problems in future or that bad behaviour—you can never rule it out—is spotted and dealt with quickly. They will come in from April 2019. In the policy design, we considered whether they should be sited with local authorities but felt that they would be better sited in trusts, so they will work in trusts, there will be provisions to deal with conflicts of interest in particular, and they will report directly to a national medical examiner. That will be their reporting line, so they will have that professional responsibility.

We will support this scheme with more money—about £30 million. It will start with hospital deaths but will roll out over time to all deaths. Clearly, as was said by the noble Baroness, Lady Wheeler, interaction with the Learning from Deaths programme, which will move from acute mental health and learning disability deaths into a primary care setting, will be critical. We need to bring these programmes together; her point was well made.

We expect that the medical examiners’ system will lead to 140 more coronial inquests each year where there is suspicion of something being not quite right. That reflects both the likelihood of problems existing in the system now and the benefits that we can get from the scheme. I hope that the scheme will get strong support from all sides of the House.

Of course, support for the affected families continues; they are still going through this process and the police assessment and investigation is moving forward. We do not believe that there are further cases on this scale but we need to remain vigilant at all times, precisely as my right honourable friend the Secretary of State said yesterday. We must make sure that we do not just think that we have solved it but keep deepening our attempt to change the culture.

The noble Baroness, Lady Wheeler, asked about medicine prescribing. At this point, the intention is to have an internal review, but we would be happy to receive evidence from all parties—noble Lords, stakeholders and others—to make sure that we can improve prescribing and look for patterns of bad behaviour. E-prescribing has been rolled out across the country, which gives us the ability to investigate unusual prescribing patterns. Improved computing technology can help us to do that as well; we are talking to the MHRA about that because it is concerned with medicine safety.

The noble Baroness, Lady Wheeler, asked about professional regulation reform. The Secretary of State is aware of it. There is a long history of great support in this House for it; I am afraid that I have not got anything particular to say to her about that at this time, other than that we are aware of the support and need for reform in this area.

Finally, the noble Baroness, Lady Jolly, asked about whistleblowers. She is absolutely right that this issue is critical, which is why we are working with the business department. The good news is that speak-up guardians, as they are sometimes known, are now in place in trusts across the country. The bad news is that, despite being banned, gagging clauses are still in operation; again, my right honourable friend said that he is determined to stamp that out. I take the noble Baroness’s point about looking at the care sector; it is a good one. I will make sure that it is considered explicitly in the work that we are doing with the business department.

Once again, I thank both noble Baronesses for their support. I know that we are all determined to make a difference.