Chapter 8: The inquests
The verdicts
The jury was tasked with determining the cause of death of each of the deceased and answering the following questions in relation to each of them:
“1. Did the administration of any medication contribute more than minimally or negligibly to the death of the deceased?
If yes:
2. Was that medication given for therapeutic purposes?
If yes:
3. Was that medication appropriate for the condition or symptoms from which the deceased was suffering?” (PCO000979)
The jury deliberated for two days and, having received a majority direction, returned the following verdicts:
“Pittock – Cause of death 1a. bronchial pneumonia 2 severe depression.
Did the administration of medication contribute more than minimally/negligibly to death? NO
Lavender – Cause of death 1a. high cervical cord injury.
Did the administration of medication contribute more than minimally/negligibly to death? YES
Was the medication given for therapeutic purposes? YES
Was medication given appropriately for condition/symptoms? YES
Service – Cause of death 1a. Congestive Heart Failure.
Did the administration of medication contribute more than minimally/negligibly to death? NO
Lake – Cause of death 1a. bronchial pneumonia 2. Fractured neck of femur repaired 5.8.99
Did the administration of medication contribute more than minimally/negligibly to death? NO
Cunningham – Cause of death 1a. bronchial pneumonia 1b. sacral ulcer. 2. Parkinson’s Disease.
Did the administration of medication contribute more than minimally/negligibly to death? YES
Was the medication given for therapeutic purposes? YES
Was medication given appropriately for condition/symptoms? YES
Wilson – Cause of death 1a. congestive cardiac failure 2. Alcoholic cirrhosis
Did the administration of medication contribute more than minimally/negligibly to death? YES
Was the medication given for therapeutic purposes? YES
Was medication given appropriately for condition/symptoms? NO
Spurgin – Cause of death 1a. infected wound 1b. fractured right hip repaired 20.03.99
Did the administration of medication contribute more than minimally/negligibly to death? NO
Packman – Cause of death 1a. gastrointestinal hemorrhage.
Did the administration of medication contribute more than minimally/negligibly to death? YES
Was the medication given for therapeutic purposes? YES
Was medication given appropriately for condition/symptoms? NO
Devine – Cause of death 1a. chronic renal failure 1b. ameloidosis 1c. IgA paraproteinaemia.
Did the administration of medication contribute more than minimally/negligibly to death? YES
Was the medication given for therapeutic purposes? YES
Was medication given appropriately for condition/symptoms? NO
Gregory – Cause of death 1a. pulmonary embolism 2. Fractured neck of femur.
Did the administration of medication contribute more than minimally/negligibly to death? NO.” (CPS000047)
Some of the family members publicly expressed their disappointment that the reports of five medical experts (Professor Ford, Professor Black, Dr Wilcock, Professor Baker and Professor Forrest) had not been put before the jury. Charles Stewart-Farthing, Mr Cunningham’s stepson, described the inquests as being “biased towards the medical profession” and said that “the whole thing has been a total waste of public money” (FAM000676, p1). In an email to Mr Sadd, Iain Wilson, Mr Wilson’s son, said of the verdict that “it might not have been what I originally hoped for, but it was certainly more than I expected”. However, he was “not happy with the outcome” (BLC001007, p1). Pauline Gregory, Mrs Gregory’s granddaughter, expressed her view that “the verdicts are a sham. It appears the only families who got a yes verdict are the loud ones who turned up every day clutching a briefcase” (BLC001009, p1).
The families called for a fresh police investigation so that criminal charges could be brought against those responsible, but Hampshire Constabulary indicated that they had no such plans (FAM002241).
Action Against Medical Accidents, a charity which had had close involvement with some of the families throughout, issued a press release stating that the verdicts “failed to satisfy the families involved … It is now quite clear that Jack Straws refusal to hold a public inquiry was wrong” (AMA100078). After the verdicts, DH maintained the position that a public inquiry should not take place. Prior to making a final decision, it said that it would await the outcome of the GMC hearing and the inquest into the death of Mrs Richards (DOH006249, p3).
Dr Barton released a statement through the Medical Defence Union saying that she was “pleased that the jury recognise that in all of these cases drugs were only given for therapeutic purposes”. Dr Barton’s husband was quoted as saying that “We’re delighted to know that they are for natural causes in all 10 cases and that the opiates were given in all 10 cases, for therapeutic reasons” (FAM000630, p2).
The Trust also sought to focus on the issue of the jury’s answers to the question of ‘therapeutic purposes’.
While expressing sympathy for the families, the press release issued by the Trust stated:
“It is important for everyone involved in the care of these patients that five verdicts indicate that the medication used to treat and relieve their symptoms did not contribute to their deaths. In two verdicts, whilst contributing to death, medication was appropriately given. It is a matter of regret to the NHS that three verdicts indicate that in the mid/late 1990s the medication administered to these patients has been found to have contributed to their deaths. However, in those cases it was found to have been given for therapeutic purposes … apologise to families concerned … the systems and policies in place at Gosport War Memorial Hospital have undergone a complete overhaul … issues highlighted … have been addressed and the care at Gosport War Memorial Hospital today is of the highest standard.” (DOH700627, p1)
The Panel is not surprised that the documents reflect the disappointment of the families with the outcome of the inquests.