Chapter 4: Healthcare organisations and individuals

Part I has described the practice of prescribing and administering drugs that were not clinically indicated and the resulting deaths. The purpose of this chapter is to examine how this pattern of practice could have remained in place undetected by others at Gosport War Memorial Hospital (‘the hospital’) for so long and the response to the concerns which did arise.

The scope of this chapter is the relevant systems and personnel in the hospital and in those NHS organisations responsible for its oversight. These included Health Authorities, NHS Trusts and NHS Commissioners, together with external health bodies such as the Commission for Health Improvement (CHI) and the Department of Health (DH). It does not cover professional regulatory bodies such as the General Medical Council (GMC) or the Nursing and Midwifery Council or its predecessor. These are covered in Chapters 6 and 7.

Systems to assure clinical quality have evolved significantly over the period covered by the Panel’s work. The term ‘clinical governance’ was not introduced until 1997, but it is used in this Report to apply to all of the systems used to assure quality, and in particular the safety of patient care.

At the start of the Panel’s timeframe, there were no formal systems to assure safety, and monitoring of patient care was rudimentary. The approach was entirely based on professional autonomy and self-regulation. Some clinicians undertook audits of their practice, but this was not mandatory and clinicians who did so were uncommon. Hospital administrators were there to facilitate the work of clinicians, and were not expected to challenge clinicians on either practice or behaviour.

In the 1980s, there were only two sources of information that might prompt concern in specific circumstances: complaints from patients and relatives, and clinical colleagues raising concerns about practice (later called whistle-blowing). Patient complaints most often prompted a defensive organisational response, with administrators preparing responses that were often less than open and transparent. On rare occasions the issues raised by complaints might have prompted referral to the GMC. More commonly, dissatisfied patients themselves took this step.

Raising concerns about clinical colleagues was fraught with peril for the whistle-blower, who was often confronted angrily by the clinician concerned, shunned by colleagues and, in some cases, obliged to emigrate to pursue their career.

The first change to this picture of complete professional autonomy began with the introduction of general management following the Griffiths Report on the NHS,¹ published in October 1983. Sir Roy Griffiths had said: “If Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge.” General management placed a manager in charge, but this was resisted strenuously by clinical professional bodies, and the view that clinicians were accountable only through professional self-regulation persisted for years in many places.²

The Health Authorities responsible for running services gradually adopted the view that clinical quality was a legitimate area of concern. There were still no formal systems to assure quality. The 1989 White Paper Working for Patients³ introduced far-reaching changes to the NHS by separating the provision of health services from their commissioning. It remained silent on quality apart from a requirement for clinical audit. Monitoring clinical quality still depended on patient complaints and occasionally on whistle-blowing.

Further change did not come until 1997 when the White Paper The New NHS: Modern, Dependable⁴ used a new term. It said that the Government “will introduce a system of ‘clinical governance’ in NHS Trusts to guarantee quality". NHS Trust Boards became formally accountable for clinical quality and were required to set up monitoring systems, including those assuring patient safety. This White Paper also led to the establishment of CHI, charged with assessing clinical quality in NHS organisations and carrying out investigations into serious failures.

NHS Trusts varied markedly in their readiness to adopt these arrangements. Some were still struggling to implement effective clinical governance over a decade later, as shown by inspections carried out across the country by CHI and its successors the Healthcare Commission and the Care Quality Commission (CQC). The requirement was clear: NHS Trusts should have had effective clinical governance, including monitoring patient safety, from around 2000 at the latest, and should from then have been well equipped to respond to any concerns that arose about the quality of clinical services.

It is important to place the documents relating to clinical governance at the hospital within this context and to take account of how it developed nationally over the time period covered by the Panel’s work.