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

Some explanation of the hospital, its background and the contemporary context will help with an understanding of the documents and the story they tell.

In many respects, developments in the NHS across the country affected Gosport War Memorial Hospital, as they did very many other hospitals. Chapters 2 and 3 explain the national framework for the prescribing and administration of opioids and other drugs, and for clinical, including nursing, standards. While that national context is paramount in understanding the events at the hospital, other factors are also important. In particular, it helps to understand the relevant geography and history of the town of Gosport and the hospital. 

Geographically, Gosport occupies a very distinct location on a peninsula in Hampshire, on the western side of Portsmouth Harbour, opposite the city of Portsmouth. By water, Gosport and Portsmouth are only separated by several hundred yards, and the journey by ferry takes less than ten minutes. The ferry service is described as one of the longest-serving in the UK. Given the extent of Portsmouth Harbour, however, the separation by road is greater, at nearly 15 miles, and the journey takes around half an hour. Gosport is about 83 miles from London, and the journey takes two hours or more by road or rail. 

Gosport’s geography has shaped its history, particularly in terms of its military significance and its hospitals. The origins of Gosport appear to lie in the village of Alverstoke, a little over a mile away, but the village still retains a separate sense of identity from Gosport town centre. During the Civil War in the 17th century, Gosport supported parliament while Portsmouth supported the king. Portsmouth was the place where the dockyards were built (dating back to the late 15th century), while Gosport provided their storehouses, timber yards and other supplies. 

The link between Gosport’s military and its hospitals is of very long standing. The Royal Naval Hospital at Haslar opened in Gosport in 1753, initially as a hospital for sick and injured sailors. Much more recently, Gosport War Memorial Hospital opened in 1923, and it is the only remaining hospital situated within Gosport itself, since the closure of Royal Hospital Haslar in 2009. There were (and still are) other hospitals in the wider Hampshire area at which the people of Gosport have been treated, including St Mary’s General Hospital and Queen Alexandra Hospital in Portsmouth.

Gosport’s pride in its military connections was reflected in the naming of the wards at Gosport War Memorial Hospital, including Ark Royal, Daedalus, Dryad and Sultan. Moreover, the town’s war memorial is situated within the grounds and is home to the annual Remembrance Day service. 

The pride of local people and their attachment to their hospital was illustrated by the successful campaign to save Gosport War Memorial Hospital from closure in the 1990s and indeed its redevelopment in 1994. 

Gosport War Memorial Hospital has developed as a community hospital. The Community Hospitals Association explains that community hospitals vary considerably, as they have adapted to the needs of their local populations, and they are highly valued and supported by local people through volunteering, fundraising, promoting and campaigning. 

In 2006, the Department of Health defined a community hospital as a service offering integrated health and social care supported by community-based professionals. The facilities of a community hospital are to be developed through negotiations between local people, practitioners and the NHS, and services offered include rehabilitation, palliative care, intermediate care, surgical care, emergency and maternity. 

In community hospitals, medical care is normally led by GPs in liaison with consultants, nursing and other health professionals as required.

Gosport War Memorial Hospital is located in Bury Road, Gosport. The hospital also included Redclyffe Annexe, situated in The Avenue, half a mile away in the direction of Alverstoke. Redclyffe Annexe is relevant to events at the hospital as described in the earlier part of this chapter, in the period up to 1994, when the Annexe closed.

In addition to Redclyffe Annexe, the events in this Report centre on Daedalus, Dryad and Sultan wards at the hospital. A major rebuild of the hospital took place between 1993 and 1994. Services for elderly male and female patients were then provided on Daedalus and Dryad wards. When Redclyffe Annexe closed, the patients and most staff were moved to Dryad Ward. Apart from Daedalus and Dryad wards, the hospital also provided a mental health inpatient unit, a small accident and emergency department and a small maternity unit.

At the time of the first recorded concern about clinical practice at the hospital in 1991, the hospital was managed by Portsmouth and South East Hampshire Health Authority, as a directly managed unit. Over the period covered by this Report, there were a number of changes to the bodies responsible for running the NHS, including the hospital. Chapter 4 refers to the relevant responsible bodies and explains their significance to the hospital at the time.