Commission for Health Improvement Report: 'Portsmouth Healthcare NHS Trust at Gosport War Memorial Hospital' including cover page reading 'Report by the Commission for Health Improvement (CHI)'

Subheadings: 1. Terms of reference and process of investigation, 2. Background to the investigation, 3. National and local context, 4. Arrangements for the prescription, administration, review and recording of medicines, 5. Quality of care and the patient experience, 6. Staffing arrangements and responsibility for patient care, 7. Lessons learnt from complaints 8. Clinical governance and Appendices. Refers to: Fiona Cameron (General Manager), Caroline Harrington (Corporate Governance Advisor), Max Millett (Chief Executive until 31 March 2002), Ian Piper (Chief Executive of Fareham and Gosport Primary Care Trust since 1 April 2002), Detective Superintendent John James (Hampshire Constabulary), Portsmouth Healthcare NHS Trust, Gosport War Memorial Hospital, police investigation, Hampshire Constabulary, Dryad ward, Daedalus ward, Wessex guidelines, Sultan ward, Health Service Commission's review, Fareham and Gosport Primary Care Trust, East Hampshire PCT, Essence of Care guidelines, Hampshire and Isle of Wight Strategic Health Authority, Department of Health, NHS south east regional office, CHI investigation team, Alan Carpenter (Chief Executive, Somerset Coast Primary Care Trust), Anne Grosskurth (CHI Support Investigations Manager), Dr Tony Luxton (Consultant Geriatrician, Cambridge City Primary Care Trust), Julie Miller (CHI Lead Investigations Manager), Maureen Morgan (Independent Consultant and former Community Trust Nurse Director), Mary Parkinson (lay member, Age Concern), Jennifer Wenborn (Independent Occupational Therapist), Liz Fradd (CHI Director of Nursing), Nan Newbury (CHI Senior Analyst), Ian Horrigan (CHI Analyst), Kellie Rehill (CHI Investigations Coordinator), medical notes review group, Dr Barry Tennison (CHI Public Health Adviser), Crown Prosecution Service, General Medical Council, United Kingdom Central Council, Nursing and Midwifery Council, Isle of Wight, Portsmouth and East Hampshire Health Authority, medicines, expert witness reports, NHS Plan, Standing Nursing and Midwifery Committee's 2001 annual report, Dignity, security and independence in old age published by NHS Plan (July 2000), Queen Alexandra hospital, St Mary's hospital, Southampton Community NHS Trust, Royal Hospital Haslar, Barthel scores, medicines, Pallaitive care handbook guidelines on clinical management (Portsmouth Healthcare NHS Trust, Portsmouth Hospitals NHS Trust and local hospice), fluids, Feeding People, Prevention and management of malnutrition (2000), Standards for health and social care services for older people (2000), Making a difference (United Kingdom Central Council, 1999), Royal College of Nursing, St James Hospital, Medicines and Prescribing Committee, Association of Chief Police Officers, A First Class Service (Department of Health), District Audit (report dated December 999), Improving quality - steps towards a first class service, CNST, Carekey (risk event database), Documents review by CHI and/or referred to in the report (Appendix A), Views from patients and relatives/friends (Appendix B), Motor Neurone Disease Association, Alzheimer's Society, League of Friends, Gosport Stroke Club, Age Concern, Portsmouth Healthcare NHS Trust staff and non executive directors interviewed by CHI (Appendix C), Meetings or telephone interviews with external agencies with an involvement in elderly care at Gosport War Memorial Hospital (Appendix D), Medical case note review team: terms of reference and membership (Appendix E), Professor Gary Ford (Professor of Pharmacology of Old Age, University of Newcastle and Freeman Hospital), Dr Keith Munday (Consultant Geriatrician, Frimley Park Hospital), Annette Goulden (Deputy Director of Nursing, NHS Trent regional office and formerly Department of Health Nursing Officer for elderly care), analgesic ladder, syringe driver and Glossary. Associated with: CPS001397 and CPS001566.