Chapter 4: Healthcare organisations and individuals
Re-emergence of 1991 concerns
Following receipt of Professor Baker’s proposals for the review, it was launched on 13 September 2002 (DOH000032, DOH000013). On 16 September, a meeting was held in the hospital to brief staff about the review. This was led by Lucy Docherty, Chair of Fareham and Gosport PCT. While waiting for the meeting to start, a senior nurse, Toni Scammell, was approached by Staff Nurse Anita Tubbritt and Nurse Beverley Turnbull and handed a folder of documents dating from 1991/92, covering the nurses’ concerns described in Chapter 1 of this Report. She realised the implications immediately: “When I read the minutes I felt sick. I considered the minutes to be very damming.” The nurses, she said, had come to her with the material because they “had seen an article in a Sunday newspaper about GWMH which stated that no one had ever brought their concerns about syringe drivers to the attention of management before” (PCO000348, p3).
From the documents reviewed by the Panel, it appears that the approach made to Nurse Scammell on 16 September was the first time that healthcare organisations other than the Trust were aware of the warnings the nurses had made 11 years earlier to previous NHS managers, warnings that had gone unheeded in the intervening period.
In her note providing a diary of events for the period from 9 September to 18 September, Lucy Docherty referred to the folder of documents provided by the nurses as “a dossier” (LDO000019, p1). For ease of reference, the term ‘nurses’ dossier’ is accordingly used in this Report to cover the papers handed to Nurse Scammell. Jan Peach, a service manager at the hospital, passed the nurses’ dossier to Lucy Docherty. Clearly grasping its significance, she wrote: “Intense concern and anxiety as to why we have never heard about this before” (LDO000019, p1).
Over the next two days there was “much debate” between senior officers of the SHA and the Directorate of Health and Social Care (a short-lived body that succeeded the Regional Office), culminating in a decision to commission an investigation into why the information in the dossier had not emerged since 1992. At the same time the decision was taken to suspend two managers who appeared to have been involved in the 1991/92 events (LDO000019). The two were Ian Piper, now Chief Executive of Fareham and Gosport PCT, and Tony Horne, now Chief Executive of East Hampshire PCT. At the request of Lucy Docherty, their suspension was to be described as “temporary redeployment” (LDO000019, p2).
On 18 September, Jane Parvin, Personnel Director of Fareham and Gosport PCT, and Betty Woodland of the Royal College of Nursing (RCN) met three nurses including Toni Scammell to question them about the background to the dossier. The nurses recalled the last meeting at the time, on 17 December 1991, as follows: “management was one side of the room and ward staff on the other … they were put on the spot … they had not got any further, they were fed up, not supported, angry and frustrated” (DOH700062, pp2–3). Asked whether things had changed after the meeting, they said that they had, briefly, but they “… started again gradually … you can only be told so many times that you don’t know what you are talking about” (DOH700062, p3). They were concerned “they would be sacked or moved … wouldn’t be supported … would be named a trouble maker” (DOH700062, p4).
It is clear from the contemporary documents that the re-emergence of the nurses’ dossier prompted significant concern locally. It was also the subject of briefing to Ministers and DH officials. On 18 September, Adrian Pollitt of the Directorate of Health and Social Care South briefed that “a number of nurses employed by Gosport PCT handed to managers of the Trust a dossier which appears to indicate that … nurses raised concerns as long ago as 1991 about high levels of prescribing of diamorphine … managers of the hospital appeared not to have taken action in a way which satisfied those nurses, despite pressure from the RCN” (DOH000168, p1). The briefing identified the managers who might have been expected to investigate the allegations in 1991 as Mr Horne; Mr Piper, CEO of Fareham and Gosport PCT, which managed the hospital; and Mr Millett, who had been made redundant in the reorganisation which took place earlier in 2002 (DOH000168, p2).
There is a file note from Portsmouth City PCT dated the same day, 18 September 2002, which records that at around 10.00am “the Health Authority [SHA] required PHCT Board papers to be located and secured … At 5.30 3 boxes of logged files were secured in a locked cabinet in a locked room at TCO [Trust Central Office, St James’ Hospital]. Sheila Clark [CEO] has both keys". Below this is a manuscript note: “Not to be destroyed or disclosed to anyone without receipt or witnesses” (DOH602094, p2).
The note records a detailed description of the contents of each box. This shows that the boxes included all of the most important papers from Portsmouth HealthCare NHS Trust over the period 1994–2002, including Board papers, Executive Team meeting papers and Clinical Management Group meeting papers. Appended is another manuscript note, “Box taken by R Samuel (SHA) 20 November 2002”, signed by Mr Richard Samuel, Assistant CEO of the SHA (DOH602094, pp3–5). The Panel has found further information on the journey of these boxes (see paragraph 4.73).
The nurses’ dossier was passed to CHI. In a CHI briefing note headed ‘Gosport Investigation – concerns raised by nurses’, and put on file on 19 September, Julie Miller, a CHI manager, said that an “early draft of the CHI report included a short paragraph stating that concerns had been expressed by nurses to the ward sister regarding prescribing. This statement was removed by the IM in later drafts as only two nurses raised this as an issue … Additional information from nurses would not have altered the report findings or recommendations” (CQC100008, p2). Gareth Cruddace, Chief Executive of the SHA, discussed the content of the nurses’ dossier with Deputy Chief Constable Ian Readhead of Hampshire Constabulary (DOH000398, p3).
On 20 September, Dr Tanner, Director of Public Health for Hampshire and Isle of Wight SHA, wrote to Mr Cruddace, his Chief Executive:
“The revelation that there was discussion as early as 1991 about the same allegations of poor prescribing practice, and that individuals involved are still active in local health services has only increased my sense of unease about the issue. On the face of it … we have either two isolated periods, 1991 and 1998-2001 when prescribing practices were questionable, or possibly a period of ten years (1991-2001) when anticipatory prescribing of opiates via syringe driver was tolerated practice. This clearly requires investigation.
We have a duty, I believe, to examine the possibility of serious management and clinical collusion in obscuring details of poor clinical quality. There is a disturbing hypothesis which, in my view, must be considered, and subjected to rigorous analysis before rejection:
- There was a culture within Gosport War Memorial Hospital during the 1990s, which tolerated the prescription of opiate analgesia in inappropriate situations and inappropriately high doses
- Local medical and nursing staff were aware of this and the likely consequences to patients
- When concerns were raised by nursing staff, the managerial and clinical response was inadequate and a culture of ‘doctor knows best’ prevailed
- The clinical response was collusive, with a desire to ‘let sleeping dogs lie’
- The emergence of complaints to the Trust in 1998 did not trigger an adequate response, because individuals were aware that a deeper analysis of the issue would potentially incriminate individuals still working in the local health system
- The response of the organisation to the police enquiries and the CHI investigation was influenced by the same considerations
- The decision taken by the Trust in March 2002, not to revisit the disciplinary investigations into involved nursing and medical staff, was partly motivated by the knowledge that their defence might include reference to formal notification of concerns dating before 1998
- The failure by the Trust to review complaints, or audit prescribing records or clinical notes relating to the period before 1997/8 was a result of the same considerations.” (DOH702005, pp2–3)
There followed a large volume of email correspondence between the SHA, the PCT, the Directorate of Health and Social Care (an organisation referred to, at the time, as DHSC, which was one of four regional organisations that briefly succeeded the previous Regional Office) and the Department of Health about the nature of a management investigation and how it should be commissioned (DOH000162, LDO000003, DOH603547, DOH000329, DOH000324). In response, Sir Liam wrote to Lord Philip Hunt, Parliamentary Under-Secretary at DH, and other Ministers on 1 October 2002. This note records that the review by Professor Baker had been commissioned publicly, and that the “intervention was not well received by the DHSC [Directorate of Health and Social Care], the Strategic Health Authority and the Primary Care Trust all of which had believed that action taken was appropriate and no further investigation was necessary. The term ‘headquarters interference’ was used” (DOH000156, p2). However, the “emergence of an old ‘dossier’ which may not have been robustly investigated at the time has led to a volte face by the parties involved and their insistence on the need for an independent inquiry … to determine the future of the managers who have been suspended” (DOH000156, p3). There were three investigations taking place (by the police, Professor Baker and the GMC). Sir Liam concluded that an independent inquiry was not appropriate to deal with one strand of these investigations (the nurses’ dossier) at this stage, but an “independent inquiry may be indicated later if the other three investigations prove the presence of untoward deaths". However, the “option of sending CHI back in to look at the dossier of nursing complaints and the actions of the NHS organisations that dealt with them at the time provides an independent and statutory basis on which to take further action” (DOH000156, p4).
Two days later, Dr Gill, Regional Director of Public Health at SERO, wrote to Marcia Fry at DH to say that “it seems appropriate for the StHA [Hampshire and Isle of Wight Strategic Health Authority] to establish its own disciplinary process-based investigation, focussing specifically on the adequacy of the organisation’s response to the expression of concerns about the quality of patient care since 1991". He also noted that the SHA “should not need to make any public announcement about this fourth stream of investigatory activity” (DOH000003, p1). Janet Walden, a DH official, wrote to Marcia Fry on the same day to say that, given that “serious concerns appear to have been raised in 1991 … there is a prima facie case to answer for lack of appropriate management action … this in itself will need some form of independent review if public confidence is to be restored” (DOH000155, p2).