Dr Jane Barton oversaw a regime of prescribing dangerous levels of opioid drugs which shortened up to 650 lives at a hospital in Hampshire between 1989 and 2000
The grieving families of up to 650 people whose lives were cut short in a hospital where patients were given huge doses of painkilling opioids have demanded criminal prosecutions over the scandal.
A damning report published today revealed ‘a disregard for human life’ at Gosport War Memorial hospital in Hampshire and ‘a culture of shortening the lives of a large number of patients’.
At least 450 people were found to have died prematurely between 1989 and 2000, the inquiry found, with an extra 200 probably affected before medical records went missing.
The inquiry focused at the actions of Dr Jane Barton, dubbed ‘Dr Opiate’, who oversaw the dishing out of the powerful painkillers. She has since retired.
The report, which follows a four-year investigation, also slammed hospital management, police, prosecutors and medical watchdogs over their failure to protect patients.
Speaking after the report was published, Anne Cunningham, whose husband Arthur died at the hospital, said: ‘These people did not deserve to be put down like a dog. These people lived their lives only for someone at the end to decide to play God and put an end to them.’
Bridget Reeves, whose grandmother Elsie Devine died in the hospital, stood before a group of grieving families and said: ‘Our vulnerable relatives were stripped of their final words to their loved ones, silenced by overdoses.
‘These horrifying, shameful, unforgivable actions need to be disclosed in a criminal court for a jury to decide.’
Families of the elderly patients who died at the Gosport War Memorial Hospital have said they will not stop fighting until those responsible have been brought to justice in a court of law
A damning report revealed the lives of more than 450 people had been shortened by the prescribing and administering of opioids without medical justification at the hospital
Families of those who died in the hospital hug today after their 20-year fight for justice
Cindy Grant, whose father Stan Carby died at the hospital, added: ‘We are hoping criminal charges should be brought against not just those in charge but those who administered the drugs as well.’
The inquiry panel found there was ‘an institutionalised regime of prescribing and administering dangerous doses’ which were not needed and relatives who complained were ‘consistently let down by those in authority – both individuals and institutions’.
There have been calls for a fresh police investigation into retired GP Dr Barton, who families accuse of being responsible for the deaths of their elderly relatives, but it remains unclear whether there is enough evidence to bring a case.
The inquiry did not assess criminal liability, but concluded: ‘The relevant public authorities will want to consider the action that now needs to be taken to further investigate what happened at the hospital.’
Police said they will assess any new information, adding: ‘It is already apparent from our early reading of the 370 pages that in its deliberations, the Panel has had sight of information that has not previously been seen by Hampshire Constabulary.’
A CPS said it will ‘take any appropriate steps as required’.
The £700,000 house Dr Barton shares with former Royal Navy Commodore husband Tim stood empty today. Neighbours suggested the couple have gone to Spain.
Cindy Grant, whose father Stan Carby died at the hospital, said of her: ‘I heard she was abroad but I didn’t expect she would have been here to face the music. We had a feeling she would be out of the country.’
A relative of one of those who died wept as families told how they were let down by the NHS, medical watchdogs and coroners
Speaking on behalf of patients’ families, Bridget Reeves, whose grandmother died in the hospital said they had been let down by every government body and quango involved
Delivering his report, Bishop James Jones, who led the inquiry, said Dr Barton was responsible for the practice of prescribing drugs which prevailed on the wards
Police to review new evidence after families’ call for charges
Hampshire police chief Olivia Pinkney
A police chief has vowed to consider ‘next steps’ following today’s damning report.
Families of those who died in Gosport have called for those responsible to face criminal charges over their actions.
Olivia Pinkney, chief constable of Hampshire Police, said: ‘Hampshire Constabulary carried out three police investigations between 1998 and 2006.
‘This involved detailed professional assessment by a number of independent medical experts and the evidence was presented to the Crown Prosecution Service and Treasury counsel, which concluded that the evidential test for prosecution as set out in the Code for Crown Prosecutors was not met.
‘Now that the report has been published and shared with us, we will take the time to read its findings carefully.
‘We will assess any new information contained within the report in conjunction with our partners in health and the Crown Prosecution Service in order to decide the next steps.’
Giving a statement outside Portsmouth Cathedral today, Bishop James Jones, who headed the inquiry, said: ‘The documents seen by the panel show that for a 12 year period a clinical assistant, Dr Barton, was responsible for the practice of prescribing which prevailed on the wards.
‘Although the consultants were not involved directly in treating patients on the wards, the medical records show that they were aware of how drugs were prescribed and administered but did not intervene to stop the practice.
‘Nurses had a responsibility to challenge prescribing where it was not in the interests of the patient.
‘The records show that the nurses did not discharge that responsibility and continued to administer the drugs prescribed.’
The Rt Rev Jones said there had been ‘lots of tears’ and ‘grieving’ when families were presented with the findings of the report on Wednesday morning.
He told a press conference the report did not explore why the practice of prescribing may have taken place at the hospital.
‘Questions about motive are beyond the terms of reference for the panel, but those are questions that will need to be prosecuted,’ he said.
Kate Blackwell QC, who served on the panel, said: ‘One family member… said that in fact for her, this was the beginning.
‘Twenty years or so too late but eventually, they were being recognised and the fault of the hospital was being recognised.
‘And they were confident that today’s report is the start of the process that should have taken place a long time ago.’
Edna Purnell, 91, died at the hospital in 1998. Her son was threatened with arrest when he tried to feed her
Bridget Reeves accuses Barton of being responsible for the death of her grandmother Elsie Devine (pictured) who died at Gosport in 1999 aged 88, weighing just seven stone
What did the Gosport inquiry find?
Here are the key findings of the Gosport Independent Panel:
– A pattern of opioid prescribing appears to have started in 1989 and ended in 2000. Nurses first raised concerns in 1991 but the warnings were ‘unheeded’.
– Evidence was found of opioid use ‘without appropriate clinical indication’ in 456 patients.
– Taking into account missing records, at least another 200 patients were ‘probably’ also affected.
– There was a ‘disregard for human life and a culture of shortening the lives of a large number of patients’.
– There was an ‘institutionalised regime’ of prescribing and administering ‘dangerous doses’ of drugs without medical justification.
– Over a 12-year period, clinical assistant Dr Jane Barton, was responsible for prescribing.
– Nurses had the responsibility to challenge prescribing, but continued to administer the drugs.
– Consultants were not involved in treating patients, but were aware of how drugs were being prescribed and ‘did not intervene to stop the practice’.
– Patients and relatives were ‘powerless’ in their relationship with professional staff.
– When relatives complained about the safety of patients and appropriateness of their care they were ‘consistently let down’ by individuals and authorities.
– The senior management of the hospital, healthcare organisations, Hampshire Police, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and the Nursing and Midwifery Council ‘all failed to act in ways that would have better protected patients and relatives’.
Theresa May apologised over the length of time it had taken families to get answers.
The deaths have already led to four police and Crown Prosecution Service probes, a General Medical Council hearing, various Health Service inquires and a special ‘death audit’ to find out why so many elderly patients died.
But all have failed to result in any criminal prosecution of anyone involved. It means families have been battling for two decades for answers.
When asked about the forthcoming report at her Georgian townhouse in Alverstoke, Gosport, this week, Dr Barton said: ‘I don’t know what will be in the report, but I don’t think it will be very pleasant. I’ve never spoken to the Press about what happened and I don’t plan to now.’
Caroline Dinenage, Conservative MP for Gosport, today said the report was ‘so much worse’ than anticipated and called for action.
She told the BBC: ‘Everybody needs to look at this document and go through it with a fine toothcomb as there are so many unanswered questions,’ she said.
‘The Crown Prosecution Service needs to look at it, Hampshire Police needs to look at it and the Government needs to look at it, not just the Department of Health, but the Home Office and the Ministry of Justice.
‘There are so many unanswered questions here and the families have waited so many years, and their questions deserve to be answered. ‘
Shadow health secretary Jonathan Ashworth said the deaths at Gosport hospital represented ‘a shameful episode in our nation’s recent history’.
Mr Ashworth told MPs that it was ‘unforgivable’ that patients expecting rehabilitation were ‘put on a terminal care pathway’.
He added: ‘Why did families who had lost loved ones have to take on such a burden, have to take on such a toll, to demand answers?
‘It’s clear that the concerns of families were too often, too readily dismissed, treated as irritants. It’s shameful, no family should be put through that.’
Mr Ashworth asked Mr Hunt to spell out how change could be implemented to ensure incidents such as this could never happen again.
Stephanie Prior, head of medical negligence at law firm Osbornes, said the Government must answer the questions posed by family members.
She said: ‘The utter disregard shown for human life is what is truly shocking, and the inquiry findings are scant comfort to the families of those who died.
‘Concerns were first raised by nursing staff back as early as 1988, yet no investigation was initiated for nearly 10 years. The scandal is that everyone may walk away from this without anyone being held responsible. Worse for the families is that the time limit for bringing medical negligence cases to seek compensation has long passed.’
The death of Arthur ‘Brian’ Cunningham (pictured), was a ‘monstrous cover-up’, his stepson has said
Gladys Richards (left) was admitted to recover from a hip operation and was prescribed morphine before her abrupt death. The MP for her area, Stephen Lloyd, has said says he will lobby in Parliament for charges to be brought in the case
Prime Minister apologises to families as Health Secretary calls for action
Prime Minister Theresa May has described events at Gosport War Memorial Hospital as ‘deeply troubling’ and apologised to families over the time it took to get answers.
Mrs May told MPs at Prime Minister’s Questions: ‘The events at Gosport Memorial Hospital were tragic, they are deeply troubling and they brought unimaginable heartache to the families concerned.
‘But they are a matter of which we should be concerned across this house.’
She said that politicians needed to address the issue of public sector bodies ‘closing ranks’, adding: ‘I’m sorry that it took so long for the families to get the answers from the NHS.’
Jeremy Hunt told MPs that ‘any further action by the relevant criminal justice and health authorities must be thorough, transparent and independent’, and suggested that Hampshire Constabulary should consider whether another force should be brought in.
Mr Hunt told MPs: ‘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 and 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.’
Health secretary Mr Hunt said that the ‘culture is changing in the NHS’, but added: ‘I don’t by any means think that we are there and I think that we will uncover from this a number of things that we’re still not getting right.’
Eastbourne MP Stephen Lloyd, whose constituent Gladys Richards died in 1998 after she was transferred to the Gosport War Memorial Hospital, has previously vowed to lobby for charges.
The family of Stan Carby, a former naval officer – who was just 65 when he died within 24 hours of being admitted for rehabilitation following a series of mini-strokes – called for a full probe into Dr Barton’s actions.
Speaking earlier this week, his daughter Cindy Grant, said: ‘The police never conducted a proper investigation into our allegations and it is time they looked at bringing criminal proceedings against those responsible. I think they ought to immediately look again at the case of Dr Jane Barton under whose care so many died.’
Enid Spurgeon, then 92, was admitted to Gosport hospital after falling and fracturing her hip in March 1999. She was admitted to Haslar Hospital where the doctors operated on her before being sent to Gosport for rehabilitation.
But her family immediately had concerns for her welfare and she died after apparently being given powerful painkillers. Nephew, Carl Jewell, said before the report: ‘Obviously something should happen and people should be held accountable.’
The inquiry published today is the latest probe into treatment at the hospital.
A ‘death audit’ report published in 2013 concluded that ‘a practice of almost routine use of opiates before death’ was in place during Dr Barton’s tenure.
The GMC investigation, completed in 2009, eight years after she was referred for a fitness to practise panel, found Dr Barton guilty of ‘serious professional misconduct’.
It heard she had a ‘brusque, unfriendly and indifferent’ manner and found her use of painkillers on the elderly ward was ‘excessive, inappropriate and potentially hazardous’.
She also displayed ‘intransigence and a worrying lack of insight’ and a ‘failure to recognise the limits of her professional competence’.
She was banned from prescribing injectable opiates or providing palliative care but was not struck off.
What could ‘Dr Opiate’ potentially be charged with?
Medical manslaughter/ gross negligence manslaughter
A GP who gives a fatal dose of drugs to a patient can be charged with manslaughter.
It is distinguished from murder by finding the absence of ‘malice aforethought’, roughly translated as an intention to kill.
There are three levels to cross the threshold for criminal manslaughter, according to Mr Robert Wheeler, director, department of clinical law at University Hospital Southampton. They are:
(i) the defendant must have breached their duty of care by virtue of their negligence
(ii) that the negligence must have caused death
(iii) that the negligence complained of must amount to ‘gross negligence’.
The latter threshold would only be made out if the jury decides as follows:
‘Having regard to the risk of death involved, [was] the conduct of the defendant so bad in the circumstances as to amount [in the jury’s mind] to a criminal act or omission?’
Sentencing: From absolute discharge to life in prison
Alternatively, the doctor could face no charge if no wrongdoing is found and there is no case to answer.
Ex-naval officer Robert Wilson (left), was admitted with a broken shoulder. He allegedly told his son ‘Help me son, they are killing me’. Geoffrey Packman (right) died, aged 66, nine days after being put in the care of Dr Barton. His family have challenged why he was given ‘end of the line’ treatment
In 2010, after reviewing the GMC findings and evidence heard at inquests into the deaths of ten patients, the CPS concluded ‘the evidence is insufficient to provide a realistic prospect of conviction for an offence of gross negligence manslaughter… in respect of each of the ten deaths reviewed’.
Dr Barton has twice been interviewed by police under caution over the ‘potential homicide’ of ten patients, but never charged.
She refused to answer some questions put to her, according to a Hampshire police report.
Oxford-educated GP, 69, with influential friends and a Navy husband was able to retire on a healthy NHS
By Guy Adams for The Daily Mail
Dr Jane Barton is the focus of a report published today which found up to 650 patients had their lives cut short after they were given large doses of painkillers on wards she ran
From the moment of her birth, Jane Ann Barton was earmarked for special treatment by the medical establishment that would one day close ranks to protect her.
When the future ‘Dr Opiate’ came into the world, in October 1948, the year the NHS was founded, her proud parents chose to place a birth announcement not in The Times, but instead in the hallowed pages of the British Medical Journal.
The daughter of a Sussex GP called John Bulstrode and his wife, Jacqueline, she grew up in an extended family peppered with eminent physicians and scientists, before fulfilling her preordained role by completing a medical degree at Oxford.
Among contemporaries at the university’s medical school was her younger brother Christopher Bulstrode, a dashing individual who would variously become an Emeritus Professor at Oxford, a trauma surgeon for British troops and a doctor on Antarctic expeditions, earning a CBE in the process.
Christopher, it later emerged, was by co-incidence serving on the council of the GMC during the early 2000s when his sister was being investigated, though he took no part in the probes.
But we digress. Barton’s career may not have been quite as glamorous as her exotic sibling’s, but it was nonetheless a model of middle-class respectability.
After qualifying as a doctor she married Timothy Barton, a Royal Navy Commodore, and followed her father into general practice, becoming a partner at the busy Forton Medical Centre in Gosport, Hampshire.
The couple had two children (at least one is believed to work in medicine), and lived in an imposing £700,000 Georgian townhouse, with a large garden, a conservatory, and, in recent years, three smart cars parked on its gravel driveway.
During their free time they indulged passions for running – the local club awards a ‘Jane Barton Plate’ for most improved female runner – and bird-watching, and moved in a smart social circle which included Peter Viggers the longstanding local MP.
‘He was in there for rehab – not to DIE’: How father, 65, who had a mini stroke was dead less than 30 hours after arriving at hospital after Dr Opiate ‘told his family to ‘let nature take its course”
Stan Carby’s family said he wasn’t in pain
Former naval officer Stan Carby was just 65 when he was sent to the hospital for rehabilitation following a series of mini-strokes.
A large man, his weight ruled out being looked after at home and he was admitted to Daedalus ward at lunchtime on 26 April 1999.
His daughter Debbie Mackay, 54, a secretary from Gosport, said: ‘Generally his health was okay and he wasn’t in any pain and he was on nothing stronger than aspirin.
‘He was there for rehab so we hoped they’d be able to get him back on his feet but the following day they told us he had taken a turn for the worse.’
She said the family was devastated when they found him lying clammy and unresponsive on the ward.
They lifted him up to help him breathe and found a tube in his back – later identified as a morphine syringe driver.
The doctors told the family they were letting ‘nature take its course’ and he died 24 hours after he was admitted for rehab.
Mrs Mackay said: ‘It can’t be right for a man who was admitted to a hospital for rehab to die the following day. We knew something wasn’t right from the start. It has been a constant battle to have our concerns taken seriously.’
Mr Carby’s daughters Cindy Grant and Debbie McKay
His widow, Rita Carby, fought tirelessly along with her daughter Cindy Grant, 44, and Debbie Mckay, 54, for justice but sadly she died in 2007 and will never see the results of the inquiry.
His daughter Cindy Grant, 44 , a cook, said: ‘It’s really upsetting my mum hasn’t been here to see this day but we are convinced the people who were responsible for this will be held to account.
‘I heard she was abroad but I didn’t expect she would have been here to face the music. We had a feeling she would be out of the country. Let’s hope she gets to hear what has happened today.
She said: ‘We are hoping criminal charges should be brought against not just those in charge but those who administered the drugs as well.’
Debbie McKay said: ‘It has been a long, long road to get to this point and it was a mixture of relief and emotion to hear what the Bishop said.’
Arthur ‘Brian’ Cunningham only went in to hospital over his bedsores
Arthur ‘Brian’ Cunningham, 79, who suffered from Parkinson’s Disease was admitted to Gosport War Memorial Hospital on 21 September 1998 suffering from bed sores.
A combination of medical problems meant he could be cantankerous.
On his first night Mr Cunningham, who was also known as Arthur, became agitated so staff at the hospital gave him diamorphine to help quieten him down.
The next day his step-son, Charles Farthing, was told by nurses the drugs had been prescribed so he would remain calm.
However diamorphine was then increased four-fold over the following days and he died five days after being admitted,
Mr Farthing said that when he heard his step-father had been admitted her travelled to Gosport to visit him.
He said: ‘At that point a man, maybe a porter or cleaner, said to me: ‘That’s the death ward,’ which seemed stupid because Brian was nowhere near death, but I didn’t think too much of it.’
He said his step-father was attached to a syringe driver for regular morphine and midazolam – a strong sedative – and was unconscious.
He said: ‘He out of this world and I thought straight away they must be killing him, because my mum had been given a syringe driver just before she died of cancer in 1989.’
He said he demanded the driver be removed by Dr Barton refused and he died just five days after being admitted.
Mr Farthing said: ‘I’d like to see some action. Barton was utterly reckless in her prescribing, utterly reckless. She gave the nurses free licence to deal with these patients as they wished.’
His wife Anne said: ‘These people did not deserve to be put down like a dog, because that is what happened. These people lived their lives only for someone at the end to decide to play God and put an end to them.’
Elsie Devine, 88, been admitted to the small community hospital when her daughter Ann, with whom Elsie lived, had to go to London.
She initially kept busy and wrote to family and friends but died a month later after suffering what her family say was a kidney infection.
Relatives say she was ‘given enough drugs to lay out a six-foot violent man’.
In a formal complaint to doctors’ watchdog the General Medical Council, her daughter Ann said: ‘On November 18 1999, my mother was administered with a 25mcg fentanyl patch that was only licensed that year to be used for ‘chronic intractable pain due to cancer’.’
Fentanyl is a powerful painkiller which is up to 100 times more potent than morphine.
The following morning, the complaint continues, ‘she was then injected with 50mg of chlorpromazine [a sedative used to treat paranoia and agitation], double the dose for a normal adult and far higher than what should be used on the frail elderly.
‘Fifty-five minutes later, our mum was started on a syringe driver with 40mg of midazolam, another strong sedative, pumping directly into her body. A further 40mg of diamorphine [a painkiller] was added, which is four times the recommended dose.’
Gladys Richards died in hospital in 1998
Gladys Richards was admitted to Gosport War Memorial Hospital in August 1998 for rehabilitation after a hip operation.
But her family became extremely concerned that very strong painkiller and sedative doses were being given to their mother even though she wasn’t in pain.
Mrs Richards died in the hospital days later, aged 91. Daughter Gillian Mackenzie then became one of the first to raise concerns about the ‘care’ patients were receiving at the hospital.
Mrs Mackenzie, now 85, said: ‘She wasn’t in any pain at all but they tried to give her diamorphine while we were there.
‘I think they wanted to keep her heavily sedated so they didn’t have to look after her. It was less work for the nurses.’
She said she was told by nurse manager Philip Beed: ‘I am going to make her life easier by giving her a shot of diamorphine.’ But she added: ‘I said ‘No you will not. You are not going to give my mother diamorphine’.’
However Mrs Richards was later sedated and given pain killers on a continuous basis and died five days later.
Jean Stevens and her husband Ernest
Jean Stevens had entered Gosport War Memorial Hospital for rehab after a stroke at the age of 73.
She was ‘bright as a button’ when she entered the now notorious Daedalus Ward in 1999. Yet she was quickly put on a cocktail of painkillers and sedatives and within two days was dead.
Her husband Ernest has been waiting for the truth about her death for nearly twenty years.
The Second World War veteran, now 92, said: ‘We had been planning a party for when she came home.
‘But the next day I went in and she was just laid out. I asked a nurse what the matter with her was and she just said: ‘I can’t really tell you’.
‘They had put her on a [drugs] pump straight away and she only opened her eyes once after that, just before she died. I truly believe my wife had quite a lot of time to go before she was put on those drugs.’
Robert Wilson begged his son to help him
Robert Wilson, 74, went into hospital for rehabilitation after a fractured shoulder. But he soon became concerned over the amount of drugs he was being given.
He begged his son Iain for help a day after being admitted with a broken arm, saying doctors were killing him.
His son told an inquest in 2009: ‘I said, ‘no they are not dad, they are trying to do their best for you’. The following day he was in a coma.’
His son said he nearly got ejected from the hospital when he questioned his father’s treatment, but now wishes he had done more to get him out.
Viggers, who stepped down in 2010 after being caught spending £1,645 of parliamentary expenses on a ‘floating duck island’ for his pond was, by further happy coincidence, of great help to Barton during the period when the appalling opioid scandal slowly escalated.
Indeed, over the course of almost a decade, the MP repeatedly used his position to question the need for further inquiries into the mysterious deaths at Gosport War Memorial Hospital.
Perhaps understandably, he was heavily criticised in yesterday’s damning report. But, again, we digress.
These days, Barton is, at 69, enjoying the eighth year of a genteel retirement, financed by a fat NHS pension which presumably helps fund regular holidays with her husband to Australia, where one of her children is thought to live, and Majorca, where she is believed to own a holiday home.
As the media descended on their home yesterday, neighbours claimed that the couple had hot-footed it to the latter destination.
When they are in Gosport, the Bartons are often to be seen pottering to the nearby shorefront, from where you can look across the Solent to the Isle of Wight, equipped with binoculars and expensive camera equipment to photograph the local wildlife.
Thanks to Timothy’s former career, both are also members of the Royal Naval Birdwatching Society.
In 2015 they even contributed an article to the society’s newsletter after joining a costly expedition to the remote Lord Howe Island in the Tasman Sea, east of Australia, to study the local flora and fauna.
In a short essay the duo were critical of a ‘frightening eradication programme’ being used by local conservationists to control invasive species which are thought to be harming the small island’s indigenous wildlife.
But what of the ‘frightening eradication scheme’ closer to home? The one which Dr Opiate oversaw at the War Memorial Hospital over the course of 12 deadly years?
By all accounts an inveterate workaholic, with a somewhat cold bedside manner, she decided from 1988 until 2000 to add to her extensive workload as a GP by taking on the now-notorious role there as clinical assistant in the ‘Department of Medicine for Elderly People’.
Under Barton, her wards, Dryad and Daedalus, became informally known to staff as ‘the end of the line.’
A GMC tribunal was told how her daily schedule involved ward rounds starting at 7.30am, followed by a full shift at her GP’s practice, before an evening round back at the hospital. She was also on call every other weekend and on regular week nights.
Evidently unable, or unwilling, to properly fulfil her arduous responsibilities, Barton presided over a deadly system of ‘pre-emptive prescribing,’ allowing nurses on the wards to increase the amount of painkillers being used without the need for her consent.
As we now know, she would communicate to staff in a sort of grim code, scribbling ‘please make comfortable’ on to the medical notes of incoming patients who would then be given huge doses of opioids, often via a device called a ‘syringe driver,’ which would pump drugs constantly into their system.
Under this regime, hundreds perished, including many elderly men and women who had been admitted with relatively minor conditions. Barton signed off 833 of their death certificates, keeping sparse and in many cases incomplete notes detailing their care.
There is no suggestion this conduct amounted to murder (critics argue she was instead criminally negligent, though the Crown Prosecution Service has on multiple occasions declined to press charges).
However her treatment of the relatives of patients was at times insufferably cruel.
Alan Lavender, whose mother Elsie was admitted to Daedalus at 83 with a broken neck, told an inquest how he’d asked Barton when she was likely to be discharged, since arrangements had to be made to take care of her cat.
‘You can get rid of the cat,’ came the reply. ‘Don’t you know your mother has come here to die?’
Lavender declared himself ‘shocked’ by the ‘cold way the news had been broken to me’.
Another grieving relative, Bridget Devine, whose 88-year-old grandmother Elsie died under Barton’s care, has branded her a ‘monster’. Since the scandal began to unravel in the late 1990s, Barton responded to growing anger over her conduct with a cold dismissiveness that borders on arrogance.
While grieving relatives have spent 20 years seeking answers about deaths of loved ones, they say she has largely refused to respond to their inquiries.
Her only extensive public statement, issued through the Medical Defence Union, claimed she was ‘faced with an excessive and increasing burden in trying to care for patients’ at the hospital, and added: ‘Throughout my career I have tried to do my very best for all my patients and have had only their interests and wellbeing at heart.’
When she’s been interviewed by police under caution over ‘potential homicide’ she has responded in similarly cynical fashion ‘through provision of prepared statements’ and refusing to answer questions.
When the Mail knocked on her door last week, she reacted with the same brand of inscrutability, saying: ‘I don’t know what will be in the report, but I don’t think it will be very pleasant. I’ve never spoken to the Press about what happened and I don’t plan to now.’
Husband Timothy, for his part, has lambasted the media for seeking to ‘find a new Harold Shipman’.
She is no Harold Shipman. But the more we find out about this ghastly scandal, and the manner in which it was covered up, the more appropriate those Shipman comparisons become.
Police, prosecutors and health bosses slammed for failing to protect patients as worried families were dismissed as ‘troublemakers’
The families of patients were dismissed as ‘troublemakers’ and their concerns were brushed over, a report has found.
Nurses first warned about the practice of prescribing and administering opioids on the ward in 1991 but were not listened to, the Gosport Independent Panel said.
When families began voicing their own concerns in 1998, organisations were more concerned with protecting their reputation than dealing with the allegations, it added.
But documents reviewed by the panel show no evidence of ‘collusion or conspiracy’ to cover-up the failures.
It should have been clear to authorities that something was awry Gosport War Memorial Hospital, today’s report found
Hospital management, healthcare watchdogs, Hampshire Constabulary and the Crown Prosecution Service were among the organisations highlighted in the report for failing ‘to act in ways that would have better protected patients and relatives’.
One document examined by the panel showed that within a week of meeting two relatives, a detective wrote: ‘I have no idea why these two sisters are so out to stir trouble.’
‘Instead of listening to the families objectively, the documents speak of a tendency to dismiss them as troublemakers,’ the report said.
The panel found multiple organisations had ‘failed to identify the nature of the underlying problem’ or deal with it.
‘The documents show that following a complaint to the Trust in 1998 and the police investigation, it should have become clear to local NHS organisations that there was a serious problem with services at the hospital,’ it said.
‘Although the successive police investigations undoubtedly complicated the NHS response, it is nevertheless remarkable that at no stage was there a public admission of failure or any public apology.
‘Nor was there proportionate clinical investigation into what had happened.
‘On the contrary, the documents show numerous instances of defensiveness and denial – to families, to the public and the media, and to health service and other organisations.’
The Gosport Independent Panel deliver their report on the scandal in Portsmouth today
In the years following, many NHS organisations and the Department of Health ‘had knowledge of at least part of the picture’, the report said.
It added: ‘Despite this, the documents make clear that no external organisation was able to intervene effectively to find out what had happened, to ensure that corrective action was taken, and to give answers that the families and the public should have had many years ago.’
The panel concluded that the documents ‘do not contain evidence’ of ‘a conspiracy between organisations to ensure that the views of the families were consistently frustrated’.
Instead it said: ‘The underlying explanation is the tendency of individuals in organisations, when faced with serious allegations, to handle them in a way that limits the impact on the organisation and its perceived reputation.’
Alarm bells: How a series of reports exposed patients’ dire treatment
There have been a series of investigations into Dr Jane Barton’s work at the hospital
In 2009, an inquest ruled that high doses of powerful painkillers and sedatives contributed to the deaths of five patients at Gosport War Memorial Hospital between 1996 and 1999.
It found three patients, Robert Wilson, 74, Elsie Devine, 88, and Geoffrey Packman, 67, died after being prescribed ‘inappropriate’ medication.
A further two, Elsie Lavender, 83, and Arthur Cunningham, 79, were given drugs that contributed to their deaths, although the pills were appropriate for their condition, Portsmouth Coroner’s Court ruled.
General Medical Council
A GMC investigation, completed in 2009, eight years after Dr Barton was referred for a fitness to practice panel, found her guilty of ‘serious professional misconduct’.
It heard she had a ‘brusque, unfriendly and indifferent’ manner and found her use of painkillers on the elderly ward was ‘excessive, inappropriate and potentially hazardous’.
She also displayed ‘intransigence and a worrying lack of insight’ and a ‘failure to recognise the limits of her professional competence’.
Dr Barton was banned from prescribing injectable opiates or providing palliative care but was not struck off. She later retired.
Baker ‘death audit’
A review into deaths at the hospital, led by Professor Richard Baker, was commissioned in 2003 but could not be published in full until 2013, while inquests were held and due to a police investigation.
The professor concluded that at Gosport Memorial there was an ‘almost routine’ use of opiates and a ‘remarkably high’ proportion of dead patients had received them.
Prof Baker said that Dr Barton may not have originated this practice but she, and other medical staff, continued it after she started working at the hospital as a part time clinical assistant in 1988.
Worryingly, his death audit said the frequent use of such drugs and sedatives may ‘almost certainly’ have shortened the lives’ of some patients who might otherwise have been discharged.
The phrase, ‘Please make comfortable’ found in many medical notes, became a euphemism for starting the patient on strong painkillers.
Families’ 20-year wait for answers after coroner, police, health bosses and the CPS investigate scores of deaths at under-fire hospital
The investigation into deaths during Dr Barton’s tenure was sparked when the family of one 91-year-old raised concerns over her care.
Twenty years on, and after a number of different authorities have mounted investigations, families are hoping someone might finally be held accountable.
1991 – Two nurses report that patients were given large doses of diamorphine instead of the sedative diazepam. Their concerns go unheeded.
August 1998 – Gladys Richards dies in Gosport War Memorial Hospital after going in for rehabilitation following a hip operation. Her family report concerns about her treatment to the police and the coroner
2001 – In the three years after Ms Richards’ family came forward, three more went to police and two more case were reported to the NHS ombudsman.
2002 – Police launch investigation into the deaths of 92 patients.
2003 – An audit of care at the hospital, published by the Department of Health, concludes that ‘a practice of almost routine use of opiates before death’ was in place during Dr Barton’s tenure.
2006 – Police files in 10 key case deaths were submitted to the Crown Prosecution Service. Families of other patients criticise their cases not being involved. CPS later says no one will face charges.
April 2009 – Inquest jury rules drugs given to five elderly people at the hospital contributed to their deaths, an inquest jury ruled.
July 2009- A General Medical Council (GMC) investigation finds Dr Barton guilty of ‘serious professional misconduct’. She was banned from prescribing injectable opiates but was not struck off.
December 2009 – In the 11 years after the first complaint, concerns about 92 deaths at the hospital were passed to Hampshire Constabulary.
2010 – After reviewing the claims in light of the inquest findings, the Crown Prosecution Service again finds there is insufficient evidence to mount a prosecution for gross negligence manslaughter in 10 key cases. Families criticise 16 months needed to deliberate.
2013 – Giving a narrative verdict in an inquest 15 years after her death, a coroner finds painkillers and sedatives contributed to the death of Gladys Richards.
2014 – An Independent Investigation into more than 90 deaths at the hospital is launched and was due to conclude in 2017.
2016 – The inquiry is extended and its publication date it put back until ‘Spring 2018’.
June 2018 – The inquiry is due to give its findings this week.