Chapter 5: Hampshire Constabulary and the Crown Prosecution Service
Second police investigation
The second police investigation was undertaken between August 1999 and April 2001 and it was conducted in the following phases:
- Phase One was conducted by Detective Chief Inspector (Det Ch Insp) Raymond Burt between August 1999 and April 2000. Det Ch Insp Burt was appointed as Senior Investigating Officer (SIO) to remedy the failings in the first police investigation, which had been identified in the police complaint investigation conducted by Det Supt Longman.
- Phase Two was also conducted by Det Ch Insp Burt between April 2000 and November 2000. Phase Two was established with the investigation elevated to the status of a Force Major Enquiry with an increase in resources being allocated to the investigation. The police investigation was given the title of Operation Rochester.
- Phase Three was conducted by Detective Superintendent (Det Supt) Jonathon (John) James between May 2001 and April 2002. It was established with a proposal to widen the investigation to include additional cases and with the purpose of investigating an unidentified number of patient deaths.
Second police investigation: Phase One
Following the outcome of the investigation into Det Con Maddison and Det Insp Morgan’s conduct during the first police investigation, in August 1999 Det Ch Insp Burt assumed responsibility for addressing any investigative shortcomings that had been identified and pursuing any other appropriate lines of enquiry in the investigation into the death of Mrs Richards. The documents indicate that Det Ch Insp Burt was the only allocated investigating officer during that time (HCO000635, pp8–15).
Writing to Mr Millett on 10 August, Det Ch Insp Burt advised him of the continuing investigation and sought his guidance in obtaining Mrs Richards’ hospital notes. He said:
“… I am not familiar with the conventions and practices governing the compilation of such notes but I imagine that details of observations made and treatment given together with the rationale for taking such action would be recorded. I understand the underlying sensitivity associated with the release of this documentation and I would welcome your advice on who to approach and what steps I must take to properly seek and obtain the information which I require …” (DOH604060, pp1–2)
The Trust received Det Ch Insp Burt’s letter but there is no record of a response from Mr Millett at that time. Nor is there any evidence that Det Ch Insp Burt considered treating Mr Millett as a potential person of interest in the investigation or considered using police powers to seize the records rather than seeking them on a voluntary basis.
On 18 August, Det Ch Insp Burt made an entry in a Police Policy File recording the fact that he had taken over the investigation to address the previous inadequacies (HCO000635, p8). The documents show that Det Ch Insp Burt did not record in his Policy File: (i) an investigation strategy, including any witness and suspect strategies, staffing, forensic and budget considerations; (ii) who the actual or potential suspects were; (iii) the resources available to him and which case papers he had received.
On 29 September, Det Ch Insp Burt met with Det Supt Longman to discuss the investigation report and the lines of enquiry (HCO000635, pp17–18). There are no documents to show which lines of enquiry were discussed.
On 7 October, Det Ch Insp Burt recorded in the Policy File that he had written to Superintendent David Lockwood, Detective Superintendent (Det Supt) Steven Watts and Detective Chief Superintendent (Det Ch Supt) Keith Akerman in order to inform them of his role and intentions (HCO000635, pp18–19).
On 8 October, Det Ch Insp Burt recorded that he had written to Mr Millett “advising him of the continuing investigation and seeking his guidance as regards the acquisition of Mrs Richards hospital notes” (HCO000635, p20).
On 19 October, Det Ch Insp Burt requested Mrs Richards’ medical records from Haslar Hospital and met with Lesley Humphrey (HCO000732, p2). On 1 November, he wrote thanking Lesley Humphrey for providing copies of Mrs Richards’ medical records. He asked for a copy of the X-rays and reiterated Lesley Humphrey’s agreement to verify that the records she had provided represented a complete set of Mrs Richards’ records. Det Ch Insp Burt added:
“I also note that you agreed to supply me with copies of any pages from the original file upon which no entries have been made. You pointed out that some of these may currently be missing from the copy file … In order to fully meet the requirements of the Criminal Procedure and Investigations Act 1996 would you please ensure that any material or other information relating to Mrs Richards, which is in the possession of the Portsmouth Health Care NHS Trust, is retained, in its original state, pending the outcome of my investigation. I appreciate that this is something which you have already agreed to do, thank you. I hope that I was able to adequately explain my role in this matter and I assure you that if it becomes necessary to interview any member of the Trust’s staff I will seek to undertake the task, by way of yourself, in a way which clearly recognises the sensitivities of this matter. I look forward to meeting you, as arranged, on Thursday the 4th November 1999 at 1230 hours in your office.” (HCO000749, pp2–3)
This meant that it had taken Hampshire Constabulary over 12 months from when the first allegation was made to secure the medical records, which was contrary to the established policing principle to secure best evidence.
On 17 November, Det Ch Insp Burt interviewed Mrs Mackenzie, three months after the start of the second investigation and over 13 months since her complaint to the police was first made (FAM002547). It took a further four months to obtain a written witness statement from Mrs Mackenzie. This was also contrary to the established policing principle to secure best evidence.
On 11 October, Det Ch Insp Burt contacted the National Crime Faculty (NCF) and was provided with a list of expert names, which included Professor Brian Livesley, consultant physician at Chelsea and Westminster Hospital (HCO502533, p3; HCO000711, p20). In 1998, the role of the NCF was to provide investigative support to major crime investigations, including assistance in identifying and using independent experts. This was an appropriate way for the police to identify and engage an expert. The decision was made to engage Professor Livesley (HCO000635, p35). On 22 November 1999, Det Ch Insp Burt wrote to Professor Livesley with a detailed summary of Mrs Richards’ case (HCO003516). He asked about Professor Livesley’s suitability and availability to assist the investigation and whether he would be able to provide an opinion on whether there was evidence to support criminal proceedings against any party to the care of Mrs Richards (p7). The Panel notes that the request from the police was expressed in terms that went beyond matters relating to Mrs Richards’ condition, the appropriateness of care and treatment, the standard of care and treatment and the cause of death.
A month later, on 21 December, Det Ch Insp Burt met Professor Livesley (HCO003503). Professor Livesley provided his draft report to Hampshire Constabulary on or about 12 May 2000 (HCO000997). It included a provisional view on the use of diamorphine by way of syringe driver. The draft report covered its use in general, the dosage in these circumstances and the lack of monitoring (which amounted to a breach of a duty of care). Professor Livesley’s view was that Mrs Richards’ death was directly attributable to the administration of the large doses of drugs that she continuously received by syringe driver between 18 and 21 August 1998; that no event occurred to break the chain of causation; and that there was no evidence that her death was caused by pneumonia. He concluded:
“It is most probable if not certain that the cause of Mrs Richards’ death was respiratory depression as a consequence of the large doses of drugs she continuously received by syringe driver from 18th August 1998 until her death on 21st August 1998 and or the effects of dehydration.” (HCO002384, p19)
Professor Livesley also confirmed that he would support allegations of assault and “the unlawful killing of Mrs Richards by gross negligence” against nursing staff and Dr Barton, and suggested that the police undertake other enquiries to determine if other patients at the hospital had been similarly affected (HCO002384, p20).
The records show that between January and March 2000, the following steps were undertaken, among others:
- On 27 January, Lesley Humphrey provided a statement to Hampshire Constabulary (HCO500214).
- On 8 February, Det Ch Insp Burt wrote to Lesley Humphrey. In this letter, he asked a series of questions about: (i) the transportation of Mrs Richards between Haslar Hospital and Gosport War Memorial Hospital; (ii) on call and consultant cover and referral policies; (iii) the use of syringe drivers including dosage levels, training and supervision; and (iv) whether any other complaints had been made about the clinical management of patients (HCO001010, pp2–5).
- On 25 February, Anne Funnell, Medical Records Manager at Haslar Hospital, provided a statement and medical records (HCO002212).
- On 31 January, Mrs Lack provided a statement (HCO110868) and Mrs Mackenzie did so on 6 March (FAM002551).
- An email on 9 March from Fiona Cameron, General Manager at the Fareham and Gosport Primary Care Trust, to Lesley Humphrey refers to a site visit by Professor Livesley, which is said to have passed off without incident (NHE000809).
The records indicate that, although a draft response was prepared (DOH103159), the Trust “never formally replied” to Det Ch Insp Burt’s letter of 8 February “as situation changed gear” (DOH604066, p1). The draft response was circulated to Mr Hooper, Barbara Robinson, Fiona Cameron and Lorna Green (Business Manager), who were in turn asked to put it to Dr Lord, Dr Barton, Nurse Beed and the Trust solicitors Beachcroft Wansbroughs for “sense check” (NHE000784, p1). On 2 April, in response, Dr Barton provided comments on matters relating to the questions about on call and consultant cover and referral policies and other complaints (NHE000784, pp4–5). Later that month, on 28 April, Dr Barton wrote tendering her resignation (NHE000212, p1).
On 12 April, Det Ch Insp Burt met with Det Ch Supt Akerman, Det Supt Watts, Superintendent (Supt) Giles Stogden and Detective Inspector (Det Insp) Shand. The briefing note for the meeting says:
“The purpose of convening this meeting is to seek the authority of the Head of CID to re-designate Operation ‘ROCHESTER’ as a Force Major Enquiry. It is recommended that this authority be granted on the basis that an exploratory investigation, conducted by DCI BURT, has revealed that there are substantial grounds for suspecting that Gladys Mable RICHARDS, aged 91 years, was unlawfully killed, by staff who were responsible for her care, at the Gosport War Memorial Hospital between the 16th August 1998 and the 22nd August 1998.” (HCO003464, p3)
Additionally, the briefing note records Professor Livesley as saying that he is “being led inexorably to the conclusion that I will be supporting an allegation of manslaughter in this case and supporting other allegations including assault and actual bodily harm” (HCO003464, p12). “This case will pivot on the evidence of Professor LIVESLEY. He is a nationally, and internationally, recognised authority in his field and his expertise and experience comes at commensurate cost” (HCO003464, p15).
The same briefing note includes a recommendation “that consideration be given to establishing an account for this enquiry on the Holmes database. This will provide for the possibility of further suspect cases being discovered when the investigation gathers pace” (HCO003464, p16).
In a reference to the possibility of corporate liability, the briefing note suggests:
“Consideration should be given to discussing this with the Media Departments of the Portsmouth (NHS) Trust and the Royal Hospital Haslar. With regard to the former there is, of course, a possible future issue of corporate liability. Advice of DCS [Detective Chief Superintendent] and Media Services Manager to be sought.” (HCO003464, p16)
The meeting on 12 April 2000 represented the end of Phase One of the second investigation which had taken six months to complete.