Chapter 5: Hampshire Constabulary and the Crown Prosecution Service
Events that prompted a new investigation
The documents show that there were a series of events which obliged Hampshire Constabulary to reverse their decision and to institute a further investigation.
Between January 2002 and June 2002, eight family members made complaints to Hampshire Constabulary regarding the police conduct of the second police investigation (CPS001015, p1; HCO502054). These complaints variously highlighted concerns about the second police investigation and the lack of communication from the police.
The Panel notes that, in her letter of complaint, Mrs Mackenzie expressed concern that the second police investigation was incomplete. In particular, she highlighted that 14 people who had previously been in contact with the police regarding deaths at the hospital had not yet been interviewed. She also raised a concern that the CPS was unaware of the additional four cases that had been selected by the police for further investigation and expert opinion in 2001. Mrs Mackenzie further highlighted that the other deaths known to the police had not been investigated at all, one of which had occurred as recently as September 2001 (CPS000991).
Mrs Mackenzie further pointed out that there were additional deaths at the hospital which Det Supt James had not taken into consideration. She suggested that the police did not want to pursue the cases in order to avoid the embarrassment of previous investigative inadequacies. Mrs Mackenzie sent her letter to Paul Kernaghan, Chief Constable, and copied it to David Blunkett as Home Secretary, Nigel Waterson MP and Peter Viggers MP, the PCA, Mr Close and Mr Perry (CPS000991).
On 17 April 2002, Ch Supt Basson instructed Chief Superintendent (Ch Supt) Daniel Clacher to gather information in relation to Det Supt James’ investigation (HCO501969). On 9 May, Ch Supt Clacher reported back (HCO501918). Four days later Ch Supt Clacher was instructed to oversee an investigation into all other complaints relating to Det Supt James and to the second police investigation (CPS001015, p1).
In May 2002, the CHI concluded its investigation and published its report in July 2002 (CPS001567). The Panel notes that the CHI investigation terms of reference were to look at “whether, since 1998 there had been a failure of trust systems to ensure good quality patient care” (CPS001567, p15), and that the key conclusions of the CHI report identified “a failure of trust systems to ensure good quality patient care” (CPS001567, p9).
On 21 July, Ch Supt Clacher submitted a further report to Assistant Chief Constable (Asst Ch Const) Phillip Jacobs and Dep Ch Const Readhead. It recognised that, although each complainant had specific grievances, he had identified a number of common points in the complaints including that “The enquiry into the death of their elderly relatives was not conducted diligently or professionally and failed to take into account all of the evidence available.” Ch Supt Clacher concluded that there was a case to answer (HCO501909, p24).
On 23 July, Dep Ch Const Readhead wrote to Roger Daw at Portsmouth CPS. He set out the background and outcome to the investigation into Mrs Richards’ death. He also explained that, although the police had decided to investigate four other similar cases, those cases had not been passed to the CPS for consideration because “they were all of a similar nature to the Richards’ case and would therefore attract similar comment from your office [the CPS]” (HCO502056, p2).
Dep Ch Const Readhead confirmed that, following receipt of Ch Supt Clacher’s report, he had taken the view that the other four cases should have been submitted to the CPS and that he had now instructed Detective Superintendent (Det Supt) Paul Stickler to collate this additional evidence and pass it to the CPS (HCO502056).
The Panel notes that Dep Ch Const Readhead also informed Mr Daw that Det Supt James had given senior police officers and regulatory bodies the impression that the four cases had been referred to the CPS when in fact they had not (HCO502056).
On 19 August, Dep Ch Const Readhead wrote to numerous family members confirming receipt of Ch Supt Clacher’s report. He informed them that Det Supt Stickler would be asked to submit Ch Supt Clacher’s report, the outstanding evidence and the CHI report to the CPS for consideration. He emphasised that this would not be a new investigation, and that no additional evidence would be sought by the police at this time (for example, see CPS000913).
A number of family members responded to Dep Ch Const Readhead expressing their concern about the content of his letter, the inadequacy of the investigation and highlighting the conclusions in the CHI report as evidence that supported their complaints and concerns (for example, see CPS000914).
Between July and September 2002, numerous family members approached Hampshire Constabulary, the CPS, the Director of Public Prosecutions and the Attorney General (for example, see CPS000925). The letters raised concerns about patient care at the hospital and the inadequacies of the police investigations. Some of the letters were also copied to Tony Blair as Prime Minister, Mr Blunkett as Home Secretary, Alan Milburn as Secretary of State for Health and Iain Duncan Smith as Leader of the Opposition.
One of the letters was from Paule Ripley, who explained that, although her husband, James Ripley, had survived his stay at the hospital in April 2000, she wished for the circumstances surrounding his care to be investigated. The nature of her concern was that, having been admitted to the hospital for rest and care to treat a serious flare-up of arthritis, her husband became unconscious on 9 May 2000. He was said to have suffered a stroke and was transferred to Haslar Hospital where, in fact, it was discovered that he had not suffered a stroke. Rather, he had suffered an analgesic overdose and was so severely dehydrated that he had been hallucinating. Mrs Ripley’s husband never returned to Gosport War Memorial Hospital after that and instead received his rehabilitation care at home. At the time of writing her letter, Mrs Ripley’s husband was alive. Mrs Ripley stated that she was aware of other cases that were similar to her husband’s (CPS000910).
On 4 September 2002, the Attorney General’s office requested that a briefing note and draft response to the letters be provided (CPS000909).
On 12 September, Det Supt Stickler provided a report for submission to the CPS, in which he stated:
“I would point out that no consideration appears to have been given as to the hospital’s liability under health and safety legislation. These enquiries are normally left to the Health and Safety Executive to investigate but equally they can be conducted by the police … The allegations being made by the families are effectively that the hospital was guilty of institutionalised euthanasia. Establishing any intent to kill would be onerous, if indeed that was the position, but if it can be established that the practices at the hospital were in themselves flawed, negligent or otherwise so dangerous that patients under their care were likely to be exposed to risks, then health and safety legislation may be an appropriate investigative approach.” (HCO501965, p2)
On 16 September, Det Supt Stickler sent Ch Supt Clacher’s report, Professor Ford’s report, Dr Mundy’s report, the clinical notes relating to Mr Cunningham, Mrs Wilkie, Mr Wilson and Mrs Page, and the CHI report to Mr Close. In his covering letter, Det Supt Stickler stated:
“Whilst it is accepted that statements would need to be obtained and probably further questions asked, the report does highlight some key findings and I would appreciate a view as to whether a prima facie case may already be established under Section 3. To conduct such a health and safety investigation would clearly be time consuming and expensive which may not be justified if the CPS were able to offer some advice at this stage as to the viability or otherwise of a prosecution.” (HCO500266, pp1–2)
On 17 September 2002, Det Supt Stickler telephoned Mr Close to discuss the further papers he had collated. In his telephone note, Mr Close recorded:
“It was not clear what papers had been collated - it seems quite clear though that no real further investigation has been carried out or any relevant evidence obtained - there are seemingly 2 lever arch folders - the second of which can basically be ignored as it contains some miscellaneous medical records - the bulk of the papers may comprise the CHI report.” (CPS000933, p1)
He stated that Det Supt Stickler "seemed very concerned that there was a very urgent and early review of the papers and advice given about possible proceedings including possible offences under section 3 of Health and Safety at Work Act” (CPS000933, p1).
As Chapter 4 has explained, Sir Liam Donaldson, the Chief Medical Officer, commissioned Professor Richard Baker to conduct a statistical analysis of mortality rates at the hospital, including an audit of use of opioids. In addition, Dep Ch Const Readhead emailed Assistant Chief Constable (Asst Ch Const) Colin Smith, Asst Ch Const Jacobs, Chief Superintendent (Ch Supt) Derek Stevens (PSD), Det Ch Supt Clacher and Det Supt Stickler, indicating that as a result of the recent developments it was imperative to appoint a new SIO with immediate effect. He recorded:
“Since we spoke yesterday other developments have occurred which in my professional judgment make it imperative that we appoint a new SIO with immediate effect to progress the submission through the CPS and to commence joint work with Professor Baker from the CMO office. I will brief you am on 13.9.02.” (HCO502354, p1)
On 16 September, a meeting was held at the hospital. As Chapter 4 explains, the purpose of the meeting was to make staff aware of the audit by Professor Baker but the folder of documents recording nurses’ concerns in 1991/92 (‘the nurses’ dossier’) was also handed over. Following an internal meeting at the hospital, Mr Cruddace telephoned Dep Ch Const Readhead on 18 September to notify him that he had a bundle of documents relating to the nurses’ concerns raised in 1991 (HCO502454).
A file note by Dep Ch Const Readhead dated 19 September 2002 recorded that he and Det Ch Supt Watts (he had been promoted in the meantime) “Agreed to raise this to a critical incident and to form a Gold Control group” (HCO502455, p1).
On 19 September, a meeting was held between senior NHS staff and police at Hampshire Constabulary Headquarters. Attendees included Dep Ch Const Readhead, Det Ch Supt Watts, Dr Simon Tanner, Director of Public Health for Hampshire and Isle of Wight Strategic Health Authority (SHA) and Gareth Cruddace, Chief Executive of Hampshire and Isle of Wight SHA (HCO501582).
As a result of this meeting, it was decided that another police investigation was required. An enquiry team would be assembled to: (i) examine the new documentation and investigate the events of 1991; (ii) review existing evidence and new material to identify any additional viable lines of enquiry; (iii) submit the new material to the experts and CPS; and (iv) examine individual and corporate liability. Additionally, there would be a press release and a freephone number publicised (CPS000379, pp3–4).
On 19 September, Det Ch Supt Watts contacted Mr Close by telephone. The note of the conversation records that Det Ch Supt Watts introduced himself as the SIO and informed Mr Close that:
“… there had been a major development. The Police do not know how but papers had been sent to the PHC [Portsmouth HealthCare NHS] Trust setting out details of various nurses concerns in 1991 regarding medical personnel, the administration of drugs and seemingly deaths at the hospital. The Trust have apparently appointed 2 senior officials to investigate. Police are to make enquiries to find out the provenance of these papers and why, seemingly, they were not brought to the attention of the police during the original enquiry. Copies of these papers and a police report will follow as soon as possible. The Police believe that these papers must be considered in detail in light of the other recent papers which they have collated.” (CPS000932, p1)