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Gosport Independent Panel: Publication of Report

Volume 643: debated on Wednesday 20 June 2018

This morning, the Gosport Independent Panel published its report on what happened at Gosport Memorial Hospital between 1987 and 2001. Its findings can only be described as truly shocking. The panel found that, over the period, the lives of more than 450 patients were shortened by clinically inappropriate use of opioid analgesics, with an additional 200 lives also likely to 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 General Medical Council, the Nursing and Midwifery Council, 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, and had the establishment listened when ordinary families raised concerns instead of treating them as “troublemakers”, many of those deaths would not have happened.

I 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 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 hon. Member for North Norfolk (Norman Lamb), 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 that 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, 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 incidents 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 Crown Prosecution Service 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 and more broadly, was there an institutional desire to blame the issues on one rogue doctor rather than to examine systemic failings that prevented issues from being picked up and dealt with quickly, driven, as the 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 that would make the catalogue of failures listed in the report less likely. These include the work of the Care Quality Commission as an independent inspectorate with a strong focus on patient safety, the introduction of the duty of candour and 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. We will do that as thoroughly and quickly as possible when we come back to the House with our full response.

Families will want to know what happens next. I hope that they and hon. Members will understand the need to avoid making any statement that could prejudice the pursuit of justice. The police, working with the Crown Prosecution Service 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 has 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 to 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 commend the role played by the current MP for the area, my hon. Friend the Member for Gosport (Caroline Dinenage), who campaigned tirelessly for an independent inquiry and is unable to be here today because she is with the affected families in Portsmouth.

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

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

“Handing over a loved one to a hospital, to doctors and nurses, is an act of trust and you take for granted that they will always do that which is best for the one you love.”

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 frontline. Working with those professionals, the Government will leave no stone unturned to restore that trust. I commend this statement to the House.

Just before I call the shadow Secretary of State—the Secretary of State made reference to this point in passing—I think that it is only fair to mention to the House that a number of colleagues whose constituencies have been affected by the events at Gosport Hospital are unable to speak in these exchanges because they serve either as Ministers or, in one case, as Parliamentary Private Secretary to the Prime Minister. It should be acknowledged and respected that a number of those affected individuals are present on the Front Bench. I am of course referring to the Minister for Care, the hon. Member for Gosport (Caroline Dinenage); the Secretary of State for International Development, the right hon. Member for Portsmouth North (Penny Mordaunt); the Under-Secretary of State for Exiting the European Union, the hon. Member for Fareham (Suella Braverman); and the hon. Member for Meon Valley (George Hollingbery).

I thank the Secretary of State for the advance copy of his statement. I welcome the tone of his remarks and the apology that he has offered on behalf of the Government and the national health service.

This is a devastating, shocking and heartbreaking report. Our thoughts must be with the families of the 456 patients whose lives were shortened. I, like the Secretary of State, pay tribute to the right hon. Member for North Norfolk (Norman Lamb), whose persistence in establishing this inquiry in the face of a bureaucracy that, in his own words, attempted to close ranks, must be applauded. I know that other Members have also played an important part, including the hon. Member for Eastbourne (Stephen Lloyd), who is in his place, and the Minister for Care, who is understandably and properly in her Gosport constituency this afternoon. I also thank all those who served on the inquiry panel, and offer particular thanks for the extraordinary dedication, calm, compassionate, relentless and determined leadership—yet again—of the former Bishop of Liverpool, James Jones, in uncovering an injustice and revealing a truth about a shameful episode in our nation’s recent history.

As the Secretary of State quoted, the Right Rev. James Jones said:

“Handing over a loved one to a hospital, to doctors and nurses, is an act of trust and you take for granted that they will always do that which is best for the one you love.”

That trust was betrayed. He continued:

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

Others will come to their own judgment, but for me that is unforgivable.

This is a substantial, 400-page report that was only published in the last hour or so, and it will take some time for the House to fully absorb each and every detail, but let me offer a few reflections and ask a few questions of the Secretary of State. Like the Secretary of State, the question that lingers in my mind is, how could this have been allowed to go on for so long? How could so many warnings go unheeded?

The report is clear that concerns were first raised by a nurse in 1991. The hospital chose not to rectify the practice of prescribing the drugs involved. Concerns were raised at a national level, and the report runs through a complicated set of back and forths between different versions of health trusts and successor health trusts, management bodies and national bodies about what to do and what sort of inquiry would be appropriate. An inquiry was eventually conducted and it found an

“almost routine use of opiates”


“almost certainly shortened the lives of some patients”.

It seems that that report was left on a shelf, gathering dust.

I am sure that many of the officials and players acted in good faith but, taken as a whole, there was a systemic failure properly to investigate what went wrong and to rectify the situation. In the words of the report, serious allegations were handled

“in a way that limits the impact on the organisation and its perceived reputation.”

The consequence of that failure was devastating.

To this day, the NHS landscape understandably remains complex and is often fragmented. How confident is the Secretary of State that similar failures—if, God forbid, they were to happen again somewhere—would be more easily rectified in the future? Equally, as the Secretary of State recognises, there are questions about Hampshire constabulary. As the report says,

“the quality of the police investigations was consistently poor.”

Why is it that the police investigated the deaths of 92 patients, yet no prosecutions were brought? The report has only just been published, but what early discussions will the Secretary of State be having with the Home Secretary to ensure that police constabularies are equipped to carry out investigations of this nature, if anything so devastating were to happen anywhere else?

What about the voice of the families? Why did families who had lost loved ones have to take on such a burden and a toll to demand answers? It is clear that the concerns of families were often too readily dismissed and treated as irritants. It is shameful. No family should be put through that. I recognise that the Secretary of State has done work on this in the past and I genuinely pay tribute to him, but how can he ensure that the family voice is heard fully in future? He is right that we must be cautious in our remarks today, but can he give me the reassurance that all the relevant authorities will properly investigate and take this further? If there is a police investigation, can he guarantee that a different force will carry it out?

I also want the Secretary of State to give us some more general reassurances. Is he satisfied that the oversight of medicines in the NHS is now tight enough that incidents such as this could never be allowed to happen again? What wider lessons are there for patient safety in the NHS? Is additional legislation now required? Does he see a need for any tightening of the draft Health Service Safety Investigations Bill to reflect the learnings from this case?

The Right Rev. James Jones has provided a serious, devastating, far-reaching service in a far-reaching report. Aggrieved families have had to suffer the most terrible injustice. In the next few weeks, we will rightly acknowledge 70 years of our national health service. The Secretary of State is right to say that this must not cast a shadow over the extraordinary work done every day by health professionals in our NHS. But on this occasion, the system has let so many down. We must ask ourselves why that was allowed to happen and dedicate ourselves to ensuring that it never happens again.

I thank the shadow Health Secretary for the considered tone of his comments. I agree with everything he says. Members across the House will understand that we are all constrained in what we can say about the individual doctor concerned—because that is now a matter for the police and the CPS to take forward—but we are not constrained in debating what system lessons can be learned, and we should debate them fully, not just today but in the future. The big question for us is not so much, “How could this have happened once?”—because in a huge healthcare system we are, unfortunately, always occasionally going to get things that go wrong, however horrific that sometimes is—but, “How could it have been allowed to go on for so long without being stopped?”

Reflecting the hon. Gentleman’s comments, the poor treatment of whistleblowers, the ignoring of families and the closing of ranks is wrong, and we must stop it. We must go further than we have gone to date. In a way, though, it is straightforward, because we know exactly what the problem is and we just have to make sure that the culture changes. The more difficult bit is where there were process issues that happened in good faith but had a terrible outcome.

In particular, this report is a salutary lesson about the importance of transparency. Obviously I had only a couple of hours to read it—so not very long—but it looks as though the Baker report was left to gather dust for 10 years, for the perfectly straightforward and understandable reason that people said that it could not be published in the course of a police investigation or while an inquest was going on. I am speculating here, but I am pretty certain that had it been published, transparency would have prompted much more rapid action, and some of the things that we may now decide to do we would have done much, much earlier. That is an incredibly powerful argument for the transparency that has sadly been lacking.

How confident can I be that this would not happen again? I do think that the culture is changing in the NHS, that the NHS is more transparent and more open, and that interactions with families are much better than they were. However, I do not, by any means, think that we are there yet. I think that we will uncover from this a number of things that we are still not getting right.

As the hon. Gentleman will understand, it is not a decision for the Government as to which police force conducts these investigations. We have separation of powers and that has to be a matter for the police. One of the things that we have to ask about police investigations is whether forces have access to the expertise they need to decide whether they should prioritise an investigation. When the medical establishment closes ranks, it can be difficult for the police to know whether they should challenge that, and it does appear that that happened in this case.

In terms of wider lessons on the oversight of medicines and the Health Service Safety Investigations Bill, we will certainly take on board whether any changes need to be made there.

The culture of closing ranks and ignoring whistleblowers in the NHS is gravely worrying. Even as a new MP, I have had constituency cases where people have alerted me to this, and I feel that it could still happen today. What implications will the report have for the wider health service, particularly for elderly care and people who have family members in these situations?

There is one very important point that the shadow Health Secretary mentioned that it is important to understand from this report. We very often have a problem where people in an end of life situation are not treated in the way that we would want for our own relatives or parents. To put it very bluntly, the worry is that someone’s end may be hastened more quickly than it should be. We have made a number of changes, including scrapping the Liverpool care pathway, which happened under the coalition Government. But in this case, these patients were not in an end of life situation. They were actually going to the hospital for rehabilitation and expecting to recover—but they were old. One of the things that we will have to try to understand—all of us—is how this could have been allowed to happen and how this culture developed. I am afraid that the report is very clear that, inasmuch as the doctor was responsible—I have to be careful with my words here—lots of other people knew what was going on.

I am very grateful to the Secretary of State for an advance copy of his statement. There is much in it that I agree with, both in tone and content.

These are truly horrific events, and our first thoughts must always be with the families of those who have been affected by this scandal. It is deeply distressing to lose a loved one in any circumstances, and the circumstances in this case, with all the press coverage, will only have amplified that distress for everyone concerned.

When the inquiry was originally announced, it was expected to take two years, and it is extremely disappointing that it has stretched out until now. There has no doubt been a catastrophic failure of monitoring and accountability, not only with regard to the doctor concerned but those who failed to investigate these actions. The Government are also included in this failure. However, I am grateful to the Secretary of State for issuing the apology that he has today, and welcome the fact that the Government will bring forward more considered responses in the autumn.

I sincerely hope that this will be the beginning of justice, and ultimately closure, for the families affected. I hope that the Secretary of State will support the opening of criminal investigations into the events following the report’s findings. The public find it very difficult to have faith in health regulators who act both as investigators and prosecutors—and even the judge—in complaints. I hope that he will look at this aspect to ensure public confidence and faith in the healthcare regulation system in the future.

I thank the hon. Gentleman for his comments and agree with what he says. Of course, if the police decide to bring forward criminal prosecutions, that would have the support of the Government, but the police must make that decision independently. If a family feel that an injustice has been done, who can they go to if they feel that ranks are being closed? I think we have made progress on that question, but we need to reflect very carefully on whether it is enough progress.

The events at the hospital and the panel’s report are of significant interest to me and my constituents, and those of my hon. Friend the Member for Meon Valley (George Hollingbery), on whose behalf I am also speaking. His constituents and mine have asked whether the families can be confident that the report’s findings will be acted on and that people will be held accountable for what happened.

My hon. Friend is right to ask that question. The best parallel is the Hillsborough process, which was also led by Bishop Jones. A similar report was published that put documents into the public arena, essentially enabling people to understand truthfully what happened. On the basis of that, inquests were reopened, criminal prosecutions happened and so on. We are at that stage of the process. I hope that the transparency and thoroughness of the report will give families hope that they are at last being listened to.

May I first thank the Secretary of State for backing and trusting my judgment in 2013, without hesitation, and proceeding with this panel inquiry? I join him in paying tribute to the work of Bishop James Jones and the whole panel. Bishop James Jones is a remarkable man who has shown extraordinary clarity of thought that has, in a very impressive way, built the trust of families who have been involved in this process.

I am not sure that I share the Secretary of State’s confidence that an earlier publication of the Baker report would have resulted in the transparency he called for, bearing in mind that I had to intervene in 2013 to stop a statement being made that there would be no public inquiry even after the publication of that report. Does he agree that we have to find a way of overcoming the problem of having different inquiries through inquests, through the police and through regulators, because, together, those stopped the vital information getting out into the public domain and stopped proper investigation into these issues? Does he also agree that we need a mechanism to ensure that in future families are never ignored again, and that when legitimate allegations of wrongdoing are made, they are investigated properly and families are involved in that process?

First, I again pay tribute to the role that the right hon. Gentleman played. One of the most difficult things for any Minister is knowing when to accept advice, which is what we do most of the time, and when to overrule it. His instincts have been proved absolutely right. It is not an easy thing to do, and it causes all sorts of feathers to be ruffled, but he stuck to his guns, and rightly so. Bishop James Jones, who is a truly remarkable public servant, talked in the Hillsborough panel report about the

“patronising disposition of unaccountable power”.

That is what we have to be incredibly on guard against.

The right hon. Gentleman is right: at the heart is the problem that we did not listen to families early enough and we did not listen to whistleblowers inside the NHS early enough. My reason for saying that all these things need to see the sunlight of transparency much sooner is frankly that if they had come to light sooner and if proper attention had been given to this in 2001—we all know that Mid Staffs started in 2005—how many other lessons and tragedies throughout the health service could have been avoided? That is why I think it would be the wrong reaction today to say that we are getting there on patient safety and that transparency problems are solved: there is a lot further to go.

Within the last few hours, I have learned that I have a constituent whose grandmother had recovered from successful hip surgery without the need for any drug interventions and was sent to Gosport War Memorial Hospital for rehabilitation, only to be given a lethal cocktail of drugs that killed her. The matter was reported to Gosport police when it happened in 1998. Does the Secretary of State agree that if people are found wilfully to have administered lethal drug doses unnecessarily, they deserve to lose their liberty, and that if people are found wilfully to have covered up such crimes—for that is what they are—they deserve to lose their jobs?

I think everyone in the House would share my right hon. Friend’s sentiments, but we have to let the law take its course, and we have to make sure that justice is done, because it has been denied for too long.

On behalf of my constituents, I thank the Secretary of State for the apology and the statement today. Can he confirm that all families affected have been contacted and say a bit more about the support that will be available to those who have lost loved ones?

I am happy to do that. All the families who think they had a relative affected have been part of the panel process, and they were all invited for a briefing by Bishop Jones this morning in Portsmouth. We will provide ongoing support and counselling if necessary through the Department of Health and Social Care, which was a specific request of Bishop Jones. We are also conscious that when people read the news, they may suddenly decide that they or a loved one were affected by this. We have set up a helpline so that people can contact us and we can help them to trace whether they too have been affected.

Does not every instance of people being scared to speak out and relatives finding it too difficult to complain underline the importance of the Healthcare Safety Investigation Branch, which the Secretary of State has established? I remind him that I am chairing the Joint Committee of both Houses that is carrying out prelegislative scrutiny of the draft Health Service Safety Investigations Bill. When we report on 24 July, will my right hon. Friend undertake to bring that into law as quickly as possible? That will afford the safe space that people need to report such matters without fear or favour.

Absolutely. I commend my hon. Friend for his work and for being one of the colleagues in this place who have thought and talked about the importance of getting the right safety culture in the NHS. The Healthcare Safety Investigation Branch matters because in situations such as this, it could have been called in, done a totally independent investigation, got to the truth of what was happening quickly and prevented a recurrence of the problem. That is one of a number of things that we need to think about.

Ten years ago, a constituent came to see me called Mrs Gillian McKenzie. She told me a story that sounded so far-fetched that I struggled to believe it. In her opinion, her mother and many other elderly people had effectively been killed before their time at a hospital in Gosport. I found it staggering. I then read the hundreds of pages of documents that this amazing woman, Mrs McKenzie, had put together over the weekend, and I came to the harrowing conclusion that there could be a chance of a significant number of early deaths at the Gosport War Memorial Hospital.

I was a candidate then, not the MP. I contacted my good friend, my right hon. Friend the Member for North Norfolk (Norman Lamb), and I took Mrs McKenzie and relatives up to London to meet him. He agreed that this could be something wicked beyond compare. Over the next few years, there was continual campaigning and lobbying, and continual pushback. Finally—I pay tribute to my right hon. Friend—we got this commission off the ground. By the way, Mr Speaker, Mrs McKenzie is now 84. I saw her on Saturday evening, wished her luck and gave her a hug. Twenty years later, we are talking about the deaths of more than 450 and possibly 600 elderly people. The relatives today got the truth.

Order. I have the very highest respect for the hon. Gentleman and for his keen interest in and experience of this issue, and I am exercising some latitude for Back Benchers and for the Secretary of State on this extremely sober matter, but I hope that the hon. Gentleman is at least approaching something that has a question mark at the end of it.

I am, Mr Speaker. I appreciate the latitude.

This has been a 10-year battle. Today, the relatives got the truth. The relatives and I demand justice. I urge the House, the Government and the police to do everything necessary to ensure that the individuals named in the report are brought to justice.

There can be no justice unless the truth is put on the table. That is the crucial first step, and now justice must proceed. I thank the hon. Gentleman for his campaign for Mrs McKenzie. Perhaps the best words I can use are these of the panel in the report:

“Yes, we have listened and yes, you, the families, were right. Your concerns are shown to be valid.”

I echo the tributes to the work of Bishop James Jones and the integrity and diligence that he and the panel have shown in conducting this inquiry. The Secretary of State has rightly focused on the impact on families, and I was pleased to hear in his statement that there will be a helpline for families who suspect that they have been affected—not least because the immediate catchment area around Gosport includes a lot of retirement homes, and many families whose elderly relatives went to the area to retire may live some distance away. Given the publicity that the report has given rise to, a considerable number of people may need to get in touch. Will he ensure that the helpline is adequately resourced?

Yes, I will absolutely do that. I ought to say that I know my hon. Friend met many families and relatives during his time as a Minister in my Department, and he always dealt with those cases with a huge amount of compassion. The facts of the matter are, according to the report, that 650-plus people had their lives shortened, but we are in touch with only about 100 families, so we are expecting more people to come forward.

I, too, join in the comments that have made about the remarkable work of Bishop James Jones—not only in this important report, but on Hillsborough and on mediating with the Government last summer about moving the contaminated blood inquiry away from the Department of Health. I seek an assurance from the Secretary of State about the approach that Bishop Jones has put forward, which is the “families first” approach. Is there now a commitment from the Government to making that approach—families first—the hallmark of any inquiry that is ever held in the future?

I think actions speak louder than words. Such an approach is what Bishop Jones requested on this occasion, and we have done that. We obviously need to think through some process issues, because when a Minister wants to report to the House, they need to be a little bit informed as to what they are talking about. However, I think we have found a way to do that with this report and with the Francis report, so I think it is a good template.

May I commend the diligence and determination of the right hon. Member for North Norfolk (Norman Lamb), without whose efforts we would not be hearing the truth today, as grim and disturbing as that truth might be? Does my right hon. Friend agree that this raises further questions about the way in which doctors’ performance and patient safety are monitored? With the GMC, doctors are in effect policing themselves. Is it not time to say that this system has to change?

We do have to ask those questions, and we have to be able to respond to the concerns of my hon. Friend and his constituents about how we can be absolutely certain there will not be a closing of ranks. My experience, however, is that doctors are very quick to want to remove those of their number who are letting the profession down because this damages everyone’s reputation. There are some very difficult questions for the GMC and for the NMC. Because their processes took so long, I do not think they can put their hand on their heart and say that they have kept patients safe during that period.

The legislation regulating both doctors and healthcare professionals is now 35 years old. It is inefficient, outdated and—as I know from a constituency case in which the individual concerned is into the fifth year of her complaint to the GMC—not user-friendly for the complainant. The GMC and other healthcare professionals want change and the Secretary of State’s Department has already consulted on change, so will he give a guarantee that he will bring forward legislation to ensure that the system is not only effective, but effective for patients who make complaints?

The right hon. Gentleman is absolutely right: we have a regulatory landscape that is very complex, does not achieve the results we want, and forces regulators to spend time doing things they do not want to do and does not give them enough time for things they do want to do. Obviously, because of the parliamentary arithmetic, if we are able to get parliamentary consensus on such a change, that would speed forward the legislation.

There are many “if onlys”, but one of them is: if only the junior doctors and others who spoke up had been listened to. I know my right hon. Friend is committed to making sure that people and whistleblowers are listened to and that he is committed to transparency. Will he say a bit more about what he is doing to make sure that everyone involved in patient care—from consultants to healthcare assistants, porters, patients and families—are listened to and that their concerns are acted on?

I think we have made progress when it comes to whistleblowing because every trust now has a “freedom to speak up” guardian—an independent person inside the trust whom clinicians can contact if they have patient safety concerns. That is a big step forward, which was recommended by Robert Francis. Where I am less clear that we have solved the problem is in relation to having someone for families to go to if they think that everyone is closing ranks, and we now need to reflect on that.

I refer the House to my entry in the Register of Members’ Financial Interests and my history of working in the NHS.

A brave nurse came forward all those many years ago to highlight a concern, but the concern was not taken forward adequately at that time. Often in these circumstances, the NHS closes ranks, management remove the individual who raises the concern—the clinician in this instance—and allows the system to continue. Is there some way of monitoring the types of concerns raised by clinicians, ensuring that the staff who raise these concerns are not themselves penalised and that the system then takes accountability forward?

The hon. Lady is absolutely right to raise that matter. The nurse concerned, Anita Tubbritt, talks in the report about her concerns and the pressure that she was put under, and it was a brave thing to do. When the hon. Lady reads the report, she will see that nurse auxiliaries and others who were not professionally trained clinicians also came forward with concerns and were also worried about the impact that doing so would have on their own career. That is what we have got to stop because, in whatever part of the UK, getting a culture in which people can speak openly about patient safety issues is absolutely essential.

I was a junior doctor at the Royal Hospital Haslar in Gosport, which is just around the corner from the Gosport War Memorial Hospital, so I know that hospital fairly well, and I also know that the people of Gosport will be disappointed and distressed by this, since they very much value their community hospital.

Does the Secretary of State agree with me that there is an issue about the governance of smaller institutions, as we have seen in the past? I in no way wish to disparage the excellent work done by community hospitals, of which I have been a champion for many years, but will he look specifically at the pages in the report that touch on this? There is an issue about governing and ensuring safety in small institutions—whether in general practice or in hospitals?

I think that that is actually an excellent point, and we should definitely look at it. Big hospitals have clear lines of accountability—boards, chief executives—but those often do not exist in community hospitals and there is no one who can say they are the boss of that trust, so we should look at that.

The grandmother of one of my constituents died in Gosport War Memorial Hospital in January 1999—in other words, after concerns were being raised by families and by staff at the hospital. The family believe that her morphine dose was well above that needed for her reported pain. I thank the Health Secretary for the tone of his statement, and I also thank Bishop Jones for the work he did on this inquiry. Does the Secretary of State believe that this report shows a need for tightening the draft Health Service Safety Investigations Bill?

I thank the hon. Lady for her comments. I do not want to jump to a conclusion about any changes to the draft Bill. However, we should definitely reflect on any legislative changes that might be needed as a result of this report, and that Bill could be a very powerful vehicle for doing so.

My right hon. Friend has mentioned trust, and as a doctor myself, I am very aware of and humbled by the fact that people come to me with their children and put their trust in me to look after them. When events such as this occur, trusts can be shaken, and it is therefore important that these things are dealt with quickly. In this case, the investigation, since complaints were first received, has been going on for far too long. What will my right hon. Friend do to reassure people that any such complaints will be dealt with much more quickly in future, and that opportunities to save lives will not be lost in the meantime?

That is the big question we have to answer for both the House and the British people. However, I would say to the hon. Lady that I am confident that, where there is unsafe practice, it is surfaced much more quickly now in the NHS than it has been in the past. I am less confident about whether we have removed the bureaucratic obstacles that mean the processes of doing such investigations are not delayed inordinately so that the broader lessons that need to be learned can be learned.

One of the reasons for the growing success of the “Getting it right first time” programme is the creation of clinician-agreed datasets. Will the Secretary of State give the House an assurance that there will in future be proper analysis of the data on the excess number of deaths and the use of this particular type of drug in excessive amounts? Such analysis would have shown this hospital as an outlier, so questions could have been asked, as is now happening successfully with the GIRFT programme.

I thank my hon. Friend for his championing of the GIRFT programme, which is incredibly powerful and successful. He will have noticed that we announced last week that we are expanding it into a national clinical information programme, which will cover more than 70% of consultants. What is disturbing in this case, though, if I may say so, is that the data was really around mortality, and we have actually had that data for this whole period. There is really nothing to stop anyone looking at data, and we can see a spike in the mortality rates in this hospital between 1997 and 2001. They go down dramatically in 2001, when the practices around opiates were changed. That is why we have to ask ourselves the very difficult question about why no one looked at that data or, if they did, why no one did anything about it.

Will the Secretary of State commit to look at the wider structural issues that affect patient safety, and particularly at things such as staffing levels and pressures on doctors and nurses?

Absolutely. One of the big lessons from this report is that we have to look at systemic issues as much as at the practice of an individual doctor or nurse.

I congratulate the Secretary of State and the right hon. Member for North Norfolk (Norman Lamb) for getting us to this point. I was deeply concerned to hear in the Secretary of State’s statement that Ministers had been given advice not to proceed with this independent panel. Is the Secretary of State convinced that Ministers are now receiving better advice?

Of course that is an issue that we will look into. I would just say, in the interests of transparency, that the Department of Health has been on the same journey as the whole of the rest of the NHS with respect to patient safety issues.

Does the Secretary of State agree that this report highlights the importance of the CQC to the NHS and patient safety? Will he consider giving that body greater regulatory powers?

The legal independence of the CQC, and its ability to act as the nation’s whistleblower-in-chief, is one of the big, important reforms of recent years, and I think that will give the public confidence. However, I do not think that that is the entire answer, and I still think there is an issue about who families go to when they think they are being ignored by the establishment.

We have had Mid Staffs, Morecambe Bay and now the Gosport War Memorial Hospital. That tells us that significant patient failures are not one-offs; indeed, the Francis report of 2013 was one of the most challenging public documents I have ever read. My right hon. Friend has made patient safety a personal priority, with his customary judgment and compassion. Can he confirm that this developing culture within the NHS remains a priority for him and that the NHS will do all that it can to protect the most frail and vulnerable that it looks after?

That is absolutely my priority, and my hon. Friend worked very closely with me on that when he was my Parliamentary Private Secretary. Changing culture is a long, long process, but I think we can start through some of the things we do in this House. Reacting afresh to this report, and not just saying, “We’ve done what we need to do, because we had Mid Staffs and Morecambe Bay,” is a very important next step.

For me, the two most shocking things are the number of deaths and the length of time it has taken for this scandal to be exposed. Further to the earlier question, until the Secretary of State overruled it, the official advice from the Department of Health was that this public inquiry should not take place. Is there going to be an official investigation into why that official advice was given and which civil servant should be held accountable for it?

We will, of course, look at that. That was why I said in my statement that there were failures by the Department of Health—the specific incident needs to be looked at—and also as the steward of the system in which so many other things went wrong.

Can the Secretary of State confirm that all deaths in the NHS will be properly assessed by a coroner or a medical examiner so that lessons can be learned and avoidable deaths minimised?

I can confirm that, from next April, all hospital deaths will be examined by an independent doctor—this is the medical examiner process. We are expanding the learning from deaths programme to primary care. That is exactly where we want to go.