Chapter 4: Healthcare organisations and individuals

On 3 July 2001, the Chief Executive of Portsmouth and South East Hampshire Health Authority, Penny Humphris, wrote to Peter Homa, Chief Executive of the newly established CHI, asking if CHI could “assist us locally with an inquiry” as she was “anxious to re-establish public confidence … The review, however, should not, concern itself with the specific circumstances of the complaints, as these are being investigated through other channels” (DOH603461, p1). There is no documentary evidence that either the Health Authority or the Trust, or their successor organisations, conducted any systematic investigation of these events. In fact, the reference to “other channels” appears to be a reference to Hampshire Constabulary.

The response from Mr Homa was that he had already been asked to look at the hospital by these other channels (DOH603436). It appears from subsequent CHI briefing that this is also a reference to the police. Records show that, in addition, CHI was notified separately of concerns in July 2001 by Professor Gary Ford, who had provided an expert report at the request of Hampshire Constabulary (CQC100980, p7). CHI decided in September 2001 to carry out an investigation on the basis of the potential wider learning for the NHS (CQC100870). The CHI briefing for its Investigations and Fast Track Programme Board on 18 September 2001 notes that “Detective Superintendent James [Hampshire Constabulary] thinks [the police investigation] is unlikely to lead to prosecution” (CQC100870, p4). 

On 15 August 2001, Mr Millett wrote to Margaret Tozer, Investigations Manager at CHI, enclosing previous papers on the complaint about Mrs Richards’ care in 1998. His covering letter emphasised that the complainant’s “concerns and questions, as brought to our attention at the time, related to the events surrounding Mrs Richards unwitnessed fall” and that the “issue of palliative care, rather than active treatment and the use of syringe driver analgesia was not part of the original complaint raised with the Trust” (NHE000767, p2).

Mrs Hutchings’ internal report for the Trust included the observation that “Sadly, Mrs. Richards’s death was not as [the complainant] had hoped it would be. She felt the use of the syringe driver made her mother become unconscious and she did not say her ‘goodbye’” (RCN000013, p6). In the version of this report included with Mr Millett’s letter to CHI, however, the reference to the syringe driver causing unconsciousness is missing and this alternative section of the report is quoted: “Sadly, Mrs. Richards last few days and her death were not how her daughters had hoped her end would be, i.e. she did not regain consciousness and they felt they could not say ‘goodbye’” (NHE000767, p24).

The CHI investigation commenced in September 2001 and was due for completion the following year. Fareham and Gosport Primary Care Trust (PCT) inherited community services, including the hospital, from Portsmouth HealthCare NHS Trust in April 2002 (CQC100980, p2). In view of the timescale, Professor Donaldson is reported as asking “for reassurance that in the context of an allegation of a ‘culture of euthanasia’ apparently made in relation to care delivered at GWMH , and since the CHI investigation will not be complete until next year, the hospital is providing safe care” (DOH000409, p2). 

In his response, Dr Mike Gill, Regional Director of Public Health at SERO, concluded that whatever had happened in the past, the hospital was, by 5 October 2001, providing safe care:

CHI interviewed Mr Millett as part of its investigation on 7 January 2002 (CQC100495). The content of the interview notes confirmed that the major focus of the interview was on the functioning of Portsmouth HealthCare NHS Trust and its clinical governance. Mr Millett’s responses were generally reassuring: he “has made major changes in last couple of years” and there is a “whole new QMS [Quality Management System] with responsibility shared by senior management".  The interview notes record that the Nurse Director “has ‘uncovered some very uncomfortable things'". Remarkably, there is nothing recorded to suggest that the interviewers asked what these were or what had been done about them (CQC100495, p1).

On 7 February, the Executive Team of Portsmouth HealthCare NHS Trust met to discuss a letter from Hampshire Constabulary. The letter enclosed three medical reports commissioned by the police that the Trust had not seen previously (DOH702173). The content prompted the Executive Team to withdraw the admission rights of Dr Barton to Sultan Ward, the GP-run ward at the hospital. Three nurses named in the medical reports were not considered to need suspension or investigation. Nor was Dr Lord, the responsible consultant, as “the criticism in the reports is to do with her supervision of the clinical assistant, not her own clinical practice” (DOH702173, p2).

Although most of this was ratified by the Trust’s Clinical Governance Panel on 21 February, a question was raised during the meeting concerning the reliance on an unknown decision by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting in relation to the three named nurses. The Trust asked if “Dr Reid would pursue the criticism in the reports about the supervision of junior staff and take whatever action was appropriate” (DOH800093, p3). The notes of this meeting, and of the following meeting of the Clinical Governance Panel on 21 March, confirmed that the Trust was taking significant steps to assure itself of the safety of contemporary patient services (DOH800091). At the same time, it is notable that there is no suggestion in any of the records of identifying how widespread the prescribing practices had been in the 1990s, nor their impact on patients.

In April, responsibility for managing the hospital passed from Portsmouth HealthCare NHS Trust to Fareham and Gosport PCT, and responsibility for oversight passed to Hampshire and Isle of Wight SHA, one of 28 SHAs in England. The establishment of PCTs and SHAs had been mandated nationally through Shifting the Balance of Power Within the NHS,⁵ published in July 2001.

On 24 May, the newly appointed Director of Public Health for Hampshire and Isle of Wight SHA, Dr Simon Tanner, wrote to the Chief Executive Officer (CEO) of Fareham and Gosport PCT, Ian Piper, following a meeting to consider the impending publication of the CHI report on the hospital. Dr Tanner’s concerns are instructive:

This list of 12 pertinent questions is important, and quoted in full, because it illustrates precisely the issues that clinical governance as understood and implemented at that time should have addressed. It is clear from Dr Tanner’s letter that they had not been. These questions (and others) were turned into a media briefing pack in preparation for the publication of the CHI report. The responses merely sought to explain why the previous organisation had not undertaken the required actions at the time (DOH700515).

The CHI investigation report was published on 3 July 2002. CHI’s conclusion was that:

The CHI report also concluded “that the trust now has adequate policies and guidelines in place which are being adhered to governing the prescription and administration of pain relieving medicines to older patients” (DOH603896, p8). Nevertheless CHI made 25 recommendations for improvement, 22 of them for the two PCTs, but observed that “CHI does not have a statutory remit to investigate either the circumstances around any particular death or the conduct of any individual” (DOH603896, p8). On 9 January 2004, the final report of the Fareham and Gosport PCT CHI Recommendations Working Group indicated that the majority of the CHI recommendations had been implemented (DOH900666).