Chapter 6: The General Medical Council
The GMC investigation: second Interim Orders Committee
On 14 August 2001, Detective Superintendent (Det Supt) Jonathon (John) James wrote to the GMC to inform it that the CPS had decided there was insufficient evidence to prosecute Dr Barton in relation to Mrs Richards, but further complaints had been made by relatives of other patients and the police needed to investigate these (GMC100829, p534).
On 6 February 2002, Det Supt James wrote to the GMC explaining that the cases of four other patients (Eva Page, Alice Wilkie, Arthur Cunningham and Robert Wilson), as well as Mrs Richards, had been considered and that no further police investigation was required (GMC101057, p1111). The police provided the GMC with documents which included three expert reports, from Professor Livesley, Professor Gary Ford and Dr Keith Mundy (GMC100917, p630). Professor Ford’s report, dated 12 December 2001, stated that the cases (of Mrs Page, Mrs Wilkie, Mr Cunningham, Mr Wilson and Mrs Richards) raised serious concerns that Dr Barton’s level of skills were not adequate at the time the patients were admitted. His conclusions were:
“7.2 … having reviewed the five cases I would consider they raise a number of concerns that merit further examination by independent enquiry. Such enquiries could be made through further police interviews or perhaps more appropriately through mechanisms within the National Health Service, such as the Commission for Health Improvement, and professional medical and nursing bodies such as the GMC or UKCC.” (GMC101057, p1189)
“7.3 My principle concerns relate to the following three areas of practice: prescription and administration of subcutaneous infusions of opiate and sedative drugs in patients with non-malignant disease, lack of training and appropriate medical supervision of decisions made by nursing staff, and the level of nursing and non-consultant medical skills on the wards in relation to the management of older people with rehabilitation needs.” (p1189)
“7.4 … Opiate and sedative drugs used were frequently used at excessive doses and in combination with often no indication for dose escalation that took place. There was a failure by medical and nursing staff to recognise or respond to severe adverse effects of depressed respiratory function and conscious level that seemed to have occurred in all five patients. Nursing and medical staff appeared to have little knowledge of the adverse effects of these drugs in older people.” (p1189)
“7.5 … There is a possibility that prescriptions of subcutaneous infusions of diamorphine, midazolam and hyoscine may have been routinely written up for many older frail patients admitted to Daedalus and Dryad wards, which nurse then had the discretion to commence. This practice if present was highly inappropriate, hazardous to patients and suggests failure of the senior hospital medical and managerial staff to monitor and supervise care on the ward. Routine use of opiate and sedative drug infusions without clear indications for their use would raise concerns that a culture of ‘involuntary euthanasia’ existed on the ward.” (p1190)
“7.6 I consider the five cases raise serious concerns about the general management of older people admitted for rehabilitation on Daedalus and Dryad wards and that the level of skills of nursing and non-consultant medical staff, particularly Dr Barton, were not adequate at the time these patients were admitted.” (p1190)
On 12 February, the GMC asked Dr Malcolm Lewis, the same Medical Screener who had reviewed the case of Mrs Richards, if the case warranted a referral back to the IOC. This was while they were waiting for the full documentation from the police, but summaries of the expert reports had been provided. Dr Lewis was told that if he needed the full reports, he should ask; the police told the GMC on 14 February that the reports would be provided (GMC101058, pp6–8).
Dr Lewis noted: “Professor Ford’s analysis of the detail of this case raises sufficient grounds to refer to IOC.” He completed the screening decision form in February 2002 (GMC100917, pp516–22).
Mr Lloyd, Counsel for the GMC, explained the history of the GMC investigation and the local restrictions that were in place. This was a reference to the voluntary restriction on prescribing opioids in Dr Barton’s GP practice, to which she had agreed in February 2002 (DOH800093). He submitted that “the voluntary arrangement into which she has entered should be formalised by conditions, perhaps along the lines of those imposed by the NHS Trust and it may be that the Committee would wish to consider imposing a condition that restricts her to NHS practice” (GMC101057, p20).
The weakness in local restrictions is evident. Without a restriction on her licence to practise, Dr Barton could move to any other Trust and work in a hospital again. Similarly, any potential employer would not automatically find details of this situation when they checked Dr Barton’s registration with the GMC, if there was no restriction on her licence. There was no guarantee that the local restrictions would continue after this hearing and, as a matter of fact, they did not continue.
Dr Barton said that, in addition to her practice as a GP and her heavy workload at the hospital, she was the Chair of the local Primary Care Group, which meant she knew “only too well that the health care trust could not afford to put any more medical input than I was giving them”. Dr Barton said that after she resigned, her role was taken by a full-time staff-grade doctor and she understood that by the time of this hearing a request had been made that two full-time staff-grade doctors were needed (GMC101057, p25).
The documents are significant in assessing what weight should be given to Dr Barton’s workload. The Panel has seen nothing in the documents to indicate that she raised concerns about her workload until she was in the process of being investigated. Dr Barton herself noted that she did raise her concerns about the levels of nursing and medical staff in writing, but not until 2000 (GMC101057, p35). This was after the police investigation had begun (GMC101012, p16; GMC101058, p27).
The defence produced evidence during the hearing which it had not presented to the GMC in advance. This included Dr Barton’s letter of resignation and other correspondence relating to the pressures on Queen Alexandra Hospital and changes in the admissions at Gosport War Memorial Hospital. The Chair said: “I assume they have been circulated.” There was no response, even though in this case the documents had not been circulated in advance (GMC101057, p32).
Counsel for the GMC was asked if he wished to ask questions of Dr Barton. No questions were asked. The documents show that the opportunity to explore the expert reports from Professor Ford, Dr Mundy and Professor Livesley was missed. This is surprising given the very serious expert concerns about Dr Barton’s prescribing. Nor was there any challenge to the newly introduced material about pressures of work. The Panel also finds this surprising.
Defence Counsel submitted that there was no evidence that the experts were aware of the limited hours worked by Dr Barton (GMC101057, p37).
One of the IOC members, Gareth Wardell, asked Dr Barton:
“In that period, say 1998 to 2000, were you experiencing dilemmas whereby – and I use the word ‘conspiracy’ advisedly, because I have the evidence from a report that I chaired during that period when I was in another post in the House of Commons, in evidence we had it said that there was a conspiracy between social services, doctors and management with regard to trying to push people who were entitled to NHS care out of hospitals into nursing homes, where they would have to pay out of their own resources. Were you in that horrible dilemma? Dr Barton said that she did not think that this was a problem in Gosport at that time.” (GMC101057, p34)
The Panel notes the terms in which this question was put, which were clearly sympathetic to Dr Barton and which appear to prejudge the outcome.
The IOC deliberated in private, then announced that “on the basis of the information available”, it had determined that the test was not met and that it was not necessary to make an interim order. The Committee gave no detail of how or why it reached this determination (GMC101057, pp38–9).