Landmark day in fight for answers into deaths

The campaign spanning nearly 20 years saw relatives of the patients dismissed as ‘troublemakers’ and their warnings ignored.

The Gosport Independent Panel looked into the historic deaths of patients at Gosport War Memorial Hospital and found opportunities to rectify health practices were missed.

Published yesterday at Portsmouth Cathedral after four years of investigation, the inquiry found nurses raised concerns about the use of drugs, in particular diamorphine, in 1991.

The Hillsborough-style report, led by Bishop James Jones, found 456 patients’ lives were shortened through prescribing and administrating opioids without medical justification. This is ‘probably’ increased by 200 despite missing medical records.

The report noted the concerns of families were not effectively addressed.

Gillian Mackenzie, whose mother Glady Richards died at the hospital in 1998, complained about her care and even informed the police. An investigation was launched but dropped in weeks.

The veteran campaigner said: ‘I said: “I want to allege a case of unlawful killing –manslaughter”.

‘The police officer said “there, there my dear you’re upset”. I rang the next morning and I said “I don’t think you’re taking me seriously, I will write up the case of manslaughter”.

‘I said “I will send you to the chief constable”. He said “do what you want” and I replied ‘that’s exactly what I will do.’

Asked if she wanted Hampshire police to investigate again, she said: ‘I hope it’s not the Met police.’

As well as families, nurses also questioned the use of the medication.

In the report, it said a staff nurse expressed concerns over the administration of drugs with syringe drivers.

‘Documents reviewed by the panel show that, between in 1991 and January 1992, a number of nurses raised concerns about the prescribing of drugs, in particular diamorphine,’ it said.

‘In doing so, the nurses involved, supported by their Royal College of Nursing branch convenor, gave the hospital the opportunity to rectify the practice.

‘In choosing not to do so, the opportunity was lost, deaths resulted and, 22 years later, it became necessary to establish this panel in order to discover the truth of what happened.

‘The documents therefore tell a story of missed opportunity and unheeded warnings.’

One document examined by the panel showed that within a week of meeting two relatives, a Hampshire police detective wrote: ‘I have no idea why these two sisters are so out to stir trouble’.

The report said: ‘Instead of listening to the families objectively, the documents speak of a tendency to dismiss them as troublemakers.’

The panel found multiple organisations had ‘failed to identify the nature of the underlying problem’ or deal with it.

The Rt Rev Jones said: ‘Many of the family members from Gosport have a background in the services.

‘They were brought up to believe that those in authority are there to serve and to protect the community.

‘The relatives did not find it easy to question those in senior positions.

‘It says something about the scale of the problem that, in the end, in spite of the culture of respecting authority, the families, as it were, broke ranks and challenged what they were being told about how their loved ones were treated and how they died.’

After reading the report, families spoke of the heartache at having to wait nearly 20 years for some answers.

Sisters Debbie McKay and Cindy Grant, from Gosport, have been looking for answers into the death of their dad Stanley Carby. He was 65 when he went into Royal Hospital Haslar after a stroke.

After responding to his treatment, he was moved to Gosport War Memorial Hospital for rehabilitation. Less than 48 hours later, he died.

Debbie, 55, said: ‘The Monday evening when he was admitted, he was sitting up in bed and talking.

‘But the next morning, we got a call to say to get our mum down to the hospital because he was deteriorating.’

Debbie said it had been a long wait for justice which was made harder when their mum died in 2007.

‘She fought alongside us until she died,’ Debbie said.

Cindy added: ‘The last 19 years have been really hard.

‘It was tough waiting for answers. It has been a long 19 years.’