Chapter 1: Unheeded warnings, the nurses’ concerns and their context

Early in 1991, Anita Tubbritt, a Staff Nurse at Gosport War Memorial Hospital (‘the hospital’), rang Keith Murray, the local branch convenor of the Royal College of Nursing (RCN) (HCO004129, p2). Staff Nurse Tubbritt expressed concerns shared by other members of the night staff working at Redclyffe Annexe over the use of diamorphine and syringe drivers. Documents make it clear that concerns had been raised earlier, in 1988 (DOH702113, p8). Redclyffe Annexe was an elderly care ward, part of the hospital, but located around half a mile away. Diamorphine is a semi-synthetic drug, first derived from morphine in 1874 and also known as heroin.

Mr Murray said that it was his normal practice when approached to arrange a meeting for the staff involved. The meeting was held in February 1991 at the home of Staff Nurse Sylvia Giffin. Five or six members of staff attended, each of whom worked at the Redclyffe Annexe. The nurses said that diamorphine “was being prescribed without due consideration being given to the use of milder sedatives first”  (HCO004129, p2). 

Mr Murray later described the concerns he had heard from the nurses in these terms: “you do not need a sledgehammer to crack a walnut” and he stated that the nurses named Dr Jane Barton, a clinical assistant who attended the annexe daily, and Dr Bob Logan, a consultant geriatrician who visited on certain days (HCO004129, p2). 

Mr Murray said that, as a result of the meeting, he felt that the nurses’ concerns were justified. He suggested that they should write to Isobel Evans, the Patient Care Manager at the hospital (HCO004129, p3). On 15 February 1991, Mr Murray wrote to Staff Nurse Giffin, providing a draft letter (TLE000128, p3). From the start, Mr Murray was concerned that the nurses would be worried about “repercussions” they might face as a result of raising their concerns. So in his letter to Staff Nurse Giffin, he reassured her that she could not be disciplined or have any action taken against her for taking this action (p2). 

Mrs Evans replied on 28 February 1991. She suggested a meeting “so that a plan of action can be determined, if necessary” (TLE000128, p4). In response, Staff Nurse Giffin agreed to see Mrs Evans and reminded her that she had asked to be accompanied by an RCN representative (p5). 

Mr Murray represented Staff Nurse Giffin at the meeting, which took place on 26 April 1991. It appears from the documents that no one other than Mrs Evans, Staff Nurse Giffin and Mr Murray attended. Mr Murray later recalled that it had been decided that a notice should be displayed within Redclyffe Annexe, stating that the RCN was now aware of the concerns and that “a meeting would be arranged where staff could attend and voice any concerns without fear of reprisals by disciplinary action" (HCO004129, p4). He added that a written policy would also be agreed on the use of syringe drivers and controlled drugs (TLE000128, pp8–10).

Four days after the meeting, Mr Murray wrote to Mrs Evans and provided an open letter designed to encourage staff to talk freely at the proposed staff meeting. In the open letter, he said that he fully supported the decision to hold a meeting with staff and to agree a written policy and said that “Mrs Evans has every wish to resolve this situation”. At the same time, in his covering letter, Mr Murray noted that “it appeared during our meeting that the issue of the syringe drivers had ‘upset’ Dr Barton”. He asked if Mrs Evans could convey his apologies to Dr Barton, adding that her clinical judgements had not been questioned. He said that Mrs Evans had described Dr Barton as “a very caring G.P.” and that “I equally know and reinforce your views”. He said that his letter could be shown to Dr Barton (DOH700073, pp9–10).

The proposed staff meeting was held at Redclyffe Annexe on 11 July 1991. As well as Mrs Evans, ten nurses attended: Sister Iris Goldsmith, Sister Gillian Hamblin, seven staff nurses including Nurse Giffin and Nurse Tubbritt, and Nurse Beverley Turnbull, an enrolled nurse. The note of the meeting, issued by Mrs Evans, records that the following concerns were expressed and discussed (DOH700073, pp11–13):

In response to the concerns raised in the meeting, Mrs Evans asked the nurses to consider a number of detailed points. The general point was made “that patients suffered distress from other symptoms besides pain but also had the right to a peaceful and dignified death. That the majority of patients had complex problems." Concluding the meeting, Mrs Evans said that she would invite Kevin Short and Steve King, Nurse Manager for Elderly Services at Queen Alexandra Hospital, to talk to staff and discuss the issues that had been raised (DOH700073, pp12–13). 

In the event, it appears that Mr King spoke to staff, along with Dr Logan, on drug control of symptoms on 20 August 1991 (CQC100068, pp1–3). No record of that meeting is available to the Panel. 

Staff Nurse Tubbritt attended a course on elderly care at the Queen Alexandra Hospital in Cosham, Portsmouth (HCO002551, p3). She later stated that her main concern at the time was that the staff responsible for setting up and administering syringe drivers had not been trained properly. She went on to say that she chose the “use and abuse of the syringe driver” as her topic, when asked to prepare a class discussion on something that bothered her at work (HCO004127, p3).

Her course tutor Gerardine Whitney, Community Tutor for Continuing Education, visited Redclyffe Annexe on 31 October 1991 at Staff Nurse Tubbritt’s request. Gerardine Whitney’s report of the meeting records the concerns of the nurses with specific examples of patients being prescribed diamorphine via syringe driver with no obvious signs of pain. Gerardine Whitney concluded her report by stating that the staff were concerned that diamorphine was being used indiscriminately, despite having reported their concerns to Mrs Evans, their manager, on 11 July 1991. The staff were also concerned that non-opioids or weak opioids were not being considered prior to the use of diamorphine (DOH600103, pp1–7). 

Gerardine Whitney circulated her report to those who attended the meeting, but also sent it to Mrs Evans, to William (Bill) Hooper, General Manager for the hospital, and to Susan Frost, Principal of the Solent School of Health Studies at Queen Alexandra Hospital. Staff Nurse Tubbritt also wrote to Mrs Evans. Mrs Evans’ reply reveals a sharp shift in tone towards the nurses, from apparently open and interested, to critical and patronising. In stating “once more” that she would welcome open discussion, she refers to “disruptive criticism which achieves nothing positive and leaves staff feeling frustrated” (FAM103794, p13).

On 7 November, within a week of Gerardine Whitney’s visit, Mrs Evans wrote to every trained member of staff at Redclyffe Annexe, and copied her letter to the Night Sister, to Dr Logan, Dr Barton and Mr Hooper. In her letter, she referred to the staff concerns as “allegations” and asked for the names of any patients where they believe diamorphine, or any other drug, had been prescribed inappropriately and requested replies “even if it is purely to state they have no concerns” (DOH000004, p19). 

Staff Nurse Giffin sent Mrs Evans’ letter of 7 November and Gerardine Whitney’s report to Mr Murray (FAM001847, p1). Mr Murray wrote to Mrs Evans on 14 November, stating that the earlier agreement for a written policy governing the use of syringe drivers and controlled drugs had not been met. He went on to say that he was “appalled that the term ‘concern’ has now been changed to ‘allegation’” and that these were now required in writing (RCN000006, p1). Mr Murray wrote at the same time to Staff Nurse Giffin, saying that, unless he heard from Mrs Evans in a positive way, he would advise that the only way of resolving the issue was to use the grievance procedure. Before doing so, he suggested a meeting with the staff concerned so that he could assure them of the RCN’s support. He also said how much he admired the staff involved “for standing up for your patients in the way that you are” (DOH700073, p18). 

Mr Murray escalated the issue by writing on 2 December to Chris West, the District General Manager at the Portsmouth and South East Hampshire Health Authority. He asked for advice and revealed that the concerns of the nurses had been dismissed as “only a small group of night staff who are ‘making waves’” (DOH700073, pp20–1). 

On 5 December, Mrs Evans sent a short memorandum to all trained staff stating that, in the absence of responses to her letter of 7 November, a meeting had been arranged for all staff members concerned about the prescribing of diamorphine. She encouraged staff to attend and said that it was not the intention to make this meeting in any way threatening to staff (DOH700073, p22). 

In a letter of 10 December, Mr Murray queried the purpose of the proposed meeting as “doubtful”, given that the concerns of the staff had been discussed earlier in the year and an agreement reached to draw up a written policy. He concluded by referring again to raising a grievance on behalf of the staff if such a policy was not to be drawn up (DOH700073, p23). At the same time, Mr Murray wrote to Staff Nurse Tubbritt, Staff Nurse Giffin and Nurse Turnbull, suggesting that the important thing to remember was that “you were the ones acting professionally and correctly, try to be assertive and don’t be fobbed off” (DOH700073, p27).

The staff meeting went ahead on 17 December. Four staff nurses, including Staff Nurse Giffin and Staff Nurse Tubbritt, and two enrolled nurses including Nurse Turnbull, attended. Sister Hamblin also attended. So too did Mrs Evans, Dr Logan and Dr Barton. The note of the meeting shows that discussion was led by Mrs Evans. She said that the issue “had put a great deal of stress on everyone particularly the medical staff, it has the potential of being detrimental to patient care and relative’s peace of mind and could undermine the good work being done in the unit if allowed to get out of hand” (HCO005892, p1). 

The nurses were cautioned to keep their comments as objective as possible, and it is clear from the note that the discussion was more limited and constrained than the discussion on 11 July or during the visit by Gerardine Whitney on 31 October. The note of the 17 December meeting emphasises that “all staff had a great respect for Dr Barton and did not question her professional judgement” (HCO005892, p3). The nurses present were clearly given the impression that, because they were the night staff, they were not seeing the whole picture of each patient’s condition. The nurses’ concern was interpreted as reflecting a lack of communication with the day staff. It was put to the nurses that, if they had concerns in future, they should approach Dr Barton or Sister Hamblin. If still concerned, they should speak to Dr Logan. The note therefore clearly shows that the nurses were told to keep any concerns within the ward rather than taking their concerns to others outside the hospital. 

After Dr Logan, Dr Barton and Sister Hamblin left the meeting, Mrs Evans asked the remaining nurses if there was any need for such a policy (as in paragraph 1.18). The note says that no one present felt that this was appropriate. Mrs Evans went on to say that she was concerned “over the manner in which these concerns had been raised as it had made people feel very threatened and defensive and stressed the need to present concerns in the agreed manner in future” (HCO005892, p3).

It appears that the meeting on 17 December had the effect of silencing the nurses’ concerns, as well as closing down the question of the written policy. 

It is apparent from a letter sent to Staff Nurse Tubbritt and Nurse Turnbull by Mr Murray on 11 January 1992 that Mr West had “passed the situation onto” Max Millett, who was then the Unit General Manager. The same letter records that Tony Horne, General Manager for the Community Unit, had been made aware of the concerns and had spoken to Mr Hooper. Mr Murray concludes his letter by suggesting that the meeting on 17 December may have alleviated the nurses’ concerns but also states that he felt that the underlying problem was still there (DOH000004, pp3–4). 

This chapter has shown that, following concerns first raised by Staff Nurse Tubbritt working in Redclyffe Annexe, Staff Nurse Giffin wrote to Mrs Evans, the Patient Services Manager, in February 1991 expressing concern over the prescribing and administration of drugs with syringe drivers. The documents reviewed by the Panel show that, between that date and January 1992, a number of nurses raised concerns about the prescribing of drugs, in particular diamorphine. In so doing, 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. The rest of this chapter provides some background to the hospital and the context in which events unfolded.