Chapter 12: Summary and conclusions

In reviewing the documents for the respective chapters, the Panel has been able to draw upon the specialist expertise of Panel members relating to the prescribing and administering of drugs, medicine for the elderly, nursing skills and care for older people, the healthcare and regulatory systems, the police and prosecutions, the coronial system, government and the media. The chapters of this Report explain how the documents reviewed add to public understanding. In this final chapter, the Panel has been able to piece together the picture that has emerged, to look across the material as a whole and to answer the questions that have arisen.

The practice of anticipatory prescribing, and of administering certain drugs in circumstances and doses beyond what would have been indicated or justified clinically, involved the consultants, the clinical assistant, the nurses and the pharmacists. It was a practice that built up and continued over many years, and lives were shortened before the pattern changed significantly from 2000. Some nurses had questioned the practice in 1991, but it continued, becoming a culture and a norm for the wards involved. It became institutionalised on the wards. 

One of the most difficult things to understand about these events is why so many people were prescribed and administered drugs that were not clinically indicated, in quantities sufficient to shorten their lives. The documents indicate two striking features. First, anticipatory prescribing was used on the basis that medication might become necessary at a time when the doctor covering a ward was unable or unwilling to attend in order to prescribe it. The documents show that inappropriate use of opioids not clinically justified became more and more common over the years up to 1994, and persisted until 1998. This created a situation where powerful and potentially lethal medication was available for a large number of patients, and was expected to be used at some point.

The second feature of note is a pattern of clinical judgements being made that patients were close to death, regardless of the purpose of their admission or the plan in place. The documents show that these judgements were often not justified clinically and did not take into account patients’ or families’ views.

It may be tempting to view what happened at the hospital in the context of public debate over end of life care, what a ‘good death’ is, and assisted dying. That would be a mistake. What happened at the hospital cannot be seen, still less justified, in that context. The patients involved were not admitted for end of life care but often for rehabilitation or respite care. The pattern of prescribing and administering drugs was excessive and inappropriate in the ways explained in this Report.

The documents show that some nurses raised concerns in 1991. Their warnings went unheeded. The Panel has considered what the documents reveal about why those in authority at the hospital did not listen effectively.

It is clear from the documents disclosed that others in the hospital had knowledge of the way that powerful medications were used and the consequential shortening of lives. Most obviously, there was the attempt by some of the nurses to raise concerns, but other individuals should also have been aware of what was happening, including consultants, other doctors, nurses and managers. Yet a striking feature of the documents is that no one attempted even to challenge these behaviours.

The documents point to an explanation in a further aspect of the culture at the hospital. Part of that culture was a legacy of the concept of ‘clinical freedom’. This held that medical decisions could not be questioned by other clinicians and managers, because they were based solely on individual professional judgement. In theory, this should have been entirely supplanted by evidence-based practice, but in many places this was slow to happen, and the documents suggest that it did not happen in the hospital in the period in question. While there should have been an accepted practice of challenge, for example from the nurses (beyond those who challenged in 1991), that was not the prevailing culture. Indeed, in accepting the medical judgement made most often by the clinical assistant, the consultants effectively supported rather than challenged the practice of prescribing and the nurses were themselves involved.

Towards the end of the 1990s, the culture of challenge should have been reinforced by the advent of clinical governance, which made clinicians and managers accountable for the quality of clinical care, crucially including patient safety. Again, this was slower to take effect in some places than others, and the disclosed documents show that this was the case in the hospital. The failure of the executive directors, including the medical director, to respond effectively to concerns about opioid prescribing raised by an external consultant physician who provided an independent report in 1999 is instructive in illustrating the rudimentary state of clinical governance at the hospital.

The disclosed material makes it clear that, notwithstanding the explanations of persistent notions of ‘clinical freedom’ and ineffective clinical governance, there were ample signs of problems that were serious enough to have overridden any concerns over professional boundaries.

Seen from this perspective, the events surrounding the nurses’ concerns of 1991 can be put into the correct context. Raising the concerns in the first place was a brave act given the culture at the hospital. There is evidence in the documents that the nurses felt ostracised as a result. After an unsatisfactory meeting at which the nurses were faced with an intimidating array of other staff, including doctors, the documents show that the nurses were dismissively told to take any future concerns up directly with the doctor whose practice they had reason to challenge. This placed the nurses in a position where the only means of pursuing their reservations was to confront, unsupported, an individual in a professionally dominant position.

The documents show that the nurses raised clear concerns in 1991, but these were ignored. From the perspective of 2018, it is hard to understand how such serious matters could be so easily discounted.

Those who raise concerns about the conduct and practice of colleagues are now widely known as ‘whistle-blowers’. To put it into context, it is generally agreed that the NHS has not been good at protecting people who take such a difficult step; as the documents make clear, the events of 1991 were no exception. Nor should the consequences for whistle-blowers be underestimated: these commonly included disciplinary action and undermining of professional credibility.

There is a wider point. The documents relating to the hospital correspond with evidence elsewhere in the health system and indeed in other sectors: organisations simply do not listen to what their frontline staff have to say. This is despite the fact that those members of staff see what is happening very clearly and can gauge its impact in practice, not least from engaging with members of the public, in this case patients and relatives.

If those responsible for the hospital had listened properly to what their own nurses said in 1991, and acted, the Panel is clear that the events described in this Report would not have followed the path they did. This should serve as a challenge to all those in positions of authority.

The failure to heed the nurses’ warnings meant that, for many years, there was no effective challenge to what was happening at the hospital. When that challenge did come from the families, the documents reveal a pattern of response that even then did not focus on their concerns or effectively address them.

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. 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 a 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.

In the years following the re-emergence of serious concerns about the hospital, beginning in 1998, many NHS organisations had knowledge of at least part of the picture: Health Authorities, Primary Care Groups and Trusts, the regional office of the NHS Executive, the Commission for Healthcare Improvement and the Department of Health. 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 the answers that the families and the public should have had many years ago.

As this Report has shown, many disparate organisations were involved from 1998, and especially from 2000, spanning the health and justice systems. Between them, as is now clear from the documents, they failed to identify the nature of the underlying problem or to deal with it effectively. It is understandable that the families in particular have sought explanations as to why this was the case. There are two broad possibilities.

First, each organisation may have acted in its own interests and those of its leaders, motivated by reputation management, career self-preservation and taking the path of least resistance. This coincidence of interests would itself lead to identical responses across organisations, without there being a conspiracy between the organisations.

The second possibility is that there was collusion – a conspiracy between organisations to ensure that the views of the families were consistently frustrated. It is not clear what the underlying motivation would be for such a course, but it is understandable that the almost uniform consistency with which all concerns were dismissed and families were rebuffed might lead to suspicions of collusion or conspiracy between organisations.

The documents the Panel has reviewed do not contain evidence in support of such collusion or conspiracy. They show that 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. This does not diminish the importance or the impact of organisations acting similarly and prioritising compliance with their own processes. Too readily opting for what is convenient within an organisational setting is the enemy of recognising the real significance of concerns and allegations.

The Panel is able to say in this case that there was a coincidence of interests across organisations; and that this may well have been sufficient to explain their conduct, including at times their dismissive treatment of the families.

Instead of listening to the families objectively, the documents speak of a tendency to dismiss them as troublemakers. For example, as Chapter 5 demonstrates, within a week of meeting two relatives, a detective constable wrote: “I have no idea why these 2 sisters are so out to stir up trouble”.