Mr Speaker, this morning the Gosport Independent Panel published its report on what happened at Gosport Memorial Hospital between 1987 and 2001. Its findings can only be described as truly shocking.
The Panel found that over the period the lives of over 450 patients were shortened by clinically inappropriate use of opioid analgesics, with an additional 200 lives also likely to be have been shortened if missing medical records are taken into account.
The first concerns were raised by brave nurse whistleblowers in 1991 – but then systematically ignored. Families first raised concerns in 1998 – and they too were ignored. In short there was a catalogue of failings by the local NHS, Hampshire Constabulary, the GMC, the NMC, the Coroners and, as steward of the system, the Department of Health.
Nothing I say today will lessen the anguish and pain of families who have campaigned for 20 years for justice after the loss of a loved one. But I can at least on behalf of the government and the NHS apologise for what happened and what they have been through. Had the establishment listened when junior NHS staff spoke out, had the establishment listened when ordinary families raised concerns instead of treating them as ‘troublemakers’, many of those deaths would not have happened.
I also want to pay tribute to those families for their courage and determination to find the truth. As Bishop James Jones, who led the Panel, says in his introduction:
What has to be recognised by those who head up our public institutions is how difficult it is for ordinary people to challenge the closing of ranks of those who hold power… It is a lonely place seeking answers that others wish you were not asking.
I also thank Bishop Jones and his panel for their extremely thorough and often harrowing work. And I particularly want to thank the Rt Hon Member for Norfolk North, 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 the families were showed the report before it was presented to Parliament. I too saw it for the first time 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 whilst inquests were concluded, but can it be right for our system to have to wait 10 years before learning critically important lessons which could save the lives of other patients?
likewise, why did the GMC and NMC, the regulators with responsibility for keeping the public safe from rogue practice, again take so long? The doctor principally involved was found guilty of serious professional misconduct in 2010, but why was there a 10-year delay before her actions were considered by a fitness to practise panel?
why did Hampshire Constabulary conduct investigations that the report says were “limited in their depth and range of offences pursued” and why did the CPS not consider corporate liability and health and safety offences?
why did the Coroner and Assistant Deputy Coroner take nearly 2 years to proceed with inquests after the CPS had decided not to prosecute?
was there an institutional desire to blame the issues on one rogue doctor rather than examine systemic failings that prevented issues being picked up and dealt with quickly, driven, as the report suggests it may have been, by a desire to protect organisational reputations?
I also want to reassure the public that important changes have taken place since these events which would make the catalogue of failures listed in the report less likely. These include the work of the CQC as an independent inspectorate with a strong focus on patient safety, the Learning from Deaths programme and establishment of medical examiners across NHS hospitals from next April.
But today’s report shows we still need to ask ourselves searching questions as to whether we have got everything right and 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 and I hope that they and Honorable Members will understand the need to avoid making any statement that could prejudice the pursuit of justice.
The police, working with the CPS and clinicians as necessary, will now carefully examine the new material in the report before determining their next steps – in particular whether criminal charges should 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 whether police investigations should be undertaken by another police force.
My department will provide support for families from today, as the Panel’s work is now concluded, and I intend to meet as many of the families as I can before we give our detailed response in the autumn. I am also delighted that Bishop James Jones has agreed to continue to provide a link to the families and 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.
For people who are reading about what happened at Gosport and who have concerns that it may have affected their loved ones, we have also put in place a helpline. The number is available on the Gosport Independent Panel website and DHSC website. And we are putting in place counselling provision for those affected by the tragic events in Gosport who would find it helpful.
Let me finish by quoting again from Bishop Jones’ foreword to the report. He talks about the sense of betrayal felt by families, because “handing over a loved one to a hospital, to doctors and nurses, is an act of trust and you take for granted they will always do that which is best for them”.
Today’s report will shake that trust, but we should not allow it to cast a shadow over the remarkable dedication of the vast majority of people working incredibly hard on the NHS frontline today. Working with them the government will leave no stone unturned to restore that trust and I commend this statement to the House.