Chapter 4: Healthcare organisations and individuals
Widening patient safety concerns
Although the Trust had failed to look for evidence of systemic problems with opioid prescribing, Hampshire Constabulary was by 2001 investigating five deaths at the hospital, and contacted CHI with its concerns (CQC100980, p7). Dr Barton had been referred to the GMC (DOH000434, p2). From this point, however, there is a lack of reference in any documentation from the Trust to suggest that it saw any clinical governance implications for itself. The deaths had become a matter for the police and for the GMC (DOH000435).
In contrast, there was an upsurge in references to the hospital and opioid prescribing there in documents from the South East Regional Office (SERO) and DH. SERO was one of eight regional offices established in 1996 as part of the NHS Management Executive, an arm’s-length body responsible for NHS performance. The initial references to the hospital were prompted by the need to brief Ministers on the adverse publicity concerning the service (DOH000453).
An internal briefing was produced within DH on 5 April 2001, following local press coverage (DOH000452). The briefing covered the complaint about Mrs Richards’ care, along with a note that the police investigation papers were with the Crown Prosecution Service; a second complaint that was not upheld by the Health Ombudsman; and a third where a complaint was not made to the Trust but reported in the local press. The briefing identifies factors common to all three, including the responsible consultant and the clinical assistant, but does not mention opioids. It concludes: “Although there are factors common to the three cases mentioned, there is not sufficient evidence, at this time, to suggest that these deaths are linked or are the result of foulplay” (DOH000453, p4).
Despite the reassuring tone of this briefing, by June 2001 DH officials had learned that the police had been in touch with both the GMC and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Allegations had been made of a “culture of euthenasia at the hospital over long period; claims that ‘troublesome’ patients were given overdoses of diamorphine”, but “police are concerned that the regulatory bodies do nothing which could impede or imperil the investigation” (DOH000451, p2).
On 20 June, the Chief Medical Officer, Professor Liam Donaldson, wrote to Ministers and senior officials in DH. He was “concerned that action to protect patients should be well co-ordinated at local level” as “everything has been left with the GMC to consider whether to suspend … Are we confident that all appropriate action has been taken? Past experience has taught that a great deal of pressure has to be exerted centrally before these issues are gripped.” He asked that progress be reviewed “as a matter of urgency” (DOH000436, p1).
Kathy Doran, a DH official, replied to Professor Donaldson on 26 June to say that she had met with colleagues from SERO and that “the local investigation has rested almost exclusively with the police” (DOH000435, p1). She copied her note to the Chief Nursing Officer, Sarah Mullally, but the Panel has seen no response from Sarah Mullally in the documents provided.
At Kathy Doran’s suggestion, Dr Peter Old, who had been appointed Director of Public Health for Portsmouth and South East Hampshire Health Authority in April 2001, had become involved and was instigating the Poorly Performing Doctors procedure for Dr Barton. It is notable that this was a procedure applicable to general practice, when the relevant events had occurred in hospital where Dr Barton had been a clinical assistant working to a consultant who retained overall responsibility for patients.