Agencies involved in Gosport hospital deaths all '˜failed'

Families holding pictures of loved ones who died at Gosport War Memorial Hospital

Criticisms have been levelled at all involved, from then Gosport MP Sir Peter Viggers – who once said ‘I like and know the hospital and the people there and would like the issue to be allowed to rest’ – to police and hospital managers of the day.

Police saw family members as ‘stirring up trouble’, and their communication with family members was ‘inadequate,’ the report said.

Three police investigations were held into the deaths.

In its report, the panel said: ‘Throughout the three police investigations, a variety of evidence was obtained which, in the panel’s view, indicated that offences under the Health and Safety at Work Act 1974, and/or corporate manslaughter, might have been committed.’

Concerns raised by Gillian Mackenzie and Lesley Lack, the daughters of patient Gladys Richards who died at the hospital after being transferred from Haslar, prompted the first investigation.

But the panel found possible witnesses were not identified, no statements were taken and no contact was made with the hospital by police to secure notes or nurses’ accounts.

The panel, led by Bishop James Jones, found ‘no investigative steps (were) taken to secure best evidence’.

In 2002 a detective superintendent recorded his decision that a ‘wider investigation’ into the deaths and ‘further investigation would not be appropriate’.

The decision was not discussed with the Crown Prosecution Service.

The decision was partly made as the General Medical Council would have a role to play in investigating.

But the report added: ‘The documents show the General Medical Council had evidence against other doctors but decided to confine its investigations to Dr (Jane) Barton.’

The first time concerns raised by nurses in 1991 were reported to someone outside the NHS organisation which ran the hospital was in 2002.

A Department of Health briefing said in 2002 there was ‘not sufficient evidence’ to suggest deaths were linked or foul play was involved.

At the time there were no formal systems to assure safety and the approach to treatment was based on professional autonomy and self-regulation.

Cases for corporate prosecutions or health and safety prosecutions were not ‘fully properly or considered’.

A CPS spokesperson said: ‘We will consider the content of the report and will take any appropriate steps as required.’