Chapter 8: The inquests

In a telephone conversation with Mrs Mackenzie on 23 May 2008, Mr Horsley said that inquests were only going to be carried out into the ten deaths identified and that he was not intending to hold inquests for any of the others, including her mother, Mrs Richards (PCO000786, p2). Mrs Richards was not one of the Category 3 cases referred to the Coroner by the police following the conclusion of Operation Rochester. In fact, Mrs Richards fell into Category 2A – ‘sub-optimal but died of natural causes’ (PCO001667).

On 22 July 2008, Bindmans LLP, the solicitors representing Mrs Mackenzie, wrote to Mr Horsley and requested that he hold an inquest into the death of Mrs Richards (PCO000255). On 11 August, Mr Horsley passed this letter on to Det Supt Williams, stating:

It would be 10 October before Hampshire Constabulary responded to the issues raised three months earlier. In doing so, Det Supt Williams provided extracts from Dr Black’s statement. Dr Black had said:

It was only after receiving this letter that Mr Horsley asked whether Mrs Richards had been buried or cremated. This was relevant because if Mrs Richards had been cremated – as she had been – the Coroner would need to seek the Secretary of State’s permission, through the Ministry of Justice, to hold an inquest. When Mr Horsley sought such permission, five weeks after receiving the letter from the police, he signalled his “intention to open Mrs Richards inquest at the earliest opportunity and to have it heard as part of the series of Gosport War Memorial Hospital inquests which are scheduled to be held in March 2009” (PCO000204).

The delay in considering and responding to the Coroner’s request effectively derailed his plan to hold this inquest along with the other ten.

The response from the Ministry of Justice to Mr Horsley’s request was painstakingly slow. On 10 December 2008, a submission was made to Bridget Prentice (a Minister at the Ministry of Justice) recommending that authority should be granted for opening an inquest into the death of Mrs Richards (MOJ000088). Mr Horsley felt compelled to write to the Ministry of Justice again in January 2009 asking if a decision had been made in relation to the case of Mrs Richards: “time is now very short for Mrs Richards’ relatives – and my deputy who is conducting these inquests on my behalf – to prepare for an inquest into Mrs Richards’ death, if such an inquest is to take place in sequence with the other inquests” (PCO000188, p1). Mr Horsley again asked that Ministry of Justice staff stress the reasons why a prompt decision was necessary to the Minister (PCO000184). However, Mr Horsley was not sent permission to hold the inquest until 28 January 2009, over two months after the request had been made and its urgency flagged (PCO000174).

The documents seen by the Panel show that there was little justification for this delay, and that important consequences flowed from it. The delay meant that the approach favoured by Mr Bradley, to hold Mrs Richards’ inquest separately from the other ten, prevailed. Mr Bradley sought to justify his view by suggesting that “the circumstances and issues surrounding [Gladys Richards’] death are different from the other deaths in Gosport War Memorial Hospital”. It was also stated that the opening of the inquest would not take place in an open court and that the inquest would not be heard with a jury (PCO000171, p1). Mrs Mackenzie wrote back to Mr Horsley expressing her surprise that her mother’s inquest was to be heard separately and without a jury (PCO000571, p2). Mr Horsley passed Mrs Mackenzie’s letter to Mr Bradley and asked him “to reconsider the situation whilst there’s still time to tack this one on with the others” (PCO000571, p1). Mr Bradley said:

The documents show little justification for the decision to hold the inquest into the death of Mrs Richards separately. The 11 cases, as they would have been, had many of the same features. Mr Horsley opened Mrs Richards’ inquest on the first of the substantive hearing days in the ten other inquests. But it opened in private; and there is no basis for doing this in the documents reviewed by the Panel.

The Panel has considered the documentation relating to the period of over four years between the opening of the inquest and the first day of evidence in Mrs Richards’ case. On 15 September 2009, Alex Marshall, Chief Constable of Hampshire Constabulary, wrote to Mr Horsley saying:

The documents show that there was a period of 11 months between Ch Const Marshall’s letter and the decision not to prosecute in the case of Mrs Richards, which was conveyed on 16 August 2010 (PCO002291). However, the documents show no justification for the further delay. It was not until 7 April 2011 that Mr Horsley wrote to Blake Lapthorn, solicitors for some of the families, and Mills & Reeve LLP, solicitors for the Trust, to inform them that he was in possession of sufficient evidence to hold an inquest into Mrs Richards’ death (PCO002107, p1; PCO002175, p1). The hearings in the substantive inquest would not begin until 9 April 2013 (PCO001583).

The inquest took place before Mr Horsley and lasted for nine days. Ten witnesses gave evidence in person and three had their statements read out (PCO001877). Mrs Mackenzie and Lesley O’Brien gave evidence in relation to their mother’s treatment, as did a number of clinicians and nursing staff involved in the treatment of Mrs Richards (PCO001858, pp1–11).

While the Coroner had determined that the inquest into the death of Mrs Richards did not engage Article 2 of the Human Rights Act, various witnesses gave evidence that went beyond simply the question as to by what means she died. Evidence was admitted in relation to the working conditions at the hospital and the fact that Dr Barton and the staff struggled to cope with the levels of work they had to deal with (PCO001858, p12). Nurse Philip Beed, Clinical Manager, stated that the families of patients being admitted to the ward had unrealistic expectations and that their hopes in relation to what could be done often could not be met because of the condition of the patients (pp21–31). Dr Richard Ian Reid, a consultant at the hospital, gave evidence in relation to anticipatory prescribing and the involvement of the consultants (p12).

Dr Barton gave evidence over the course of two days at the inquest. She accepted that the standard of her note keeping was poor, that she had had little time to spend with patients, and that there had been a change in practice at the ward after she resigned (PCO001858, p41).

Both Professor Robin Ferner and Professor Black gave expert evidence. Professor Ferner’s opinion was that it was “likely” that the subcutaneous administration of diamorphine (that is, by syringe driver) had hastened Mrs Richards’ death. Sedation could lead to the inability to swallow, which in turn could lead to kidney failure (PCO001859, pp9–11). Professor Black considered Mrs Richards’ death to be due to a more complex set of circumstances. Factors that had played a part included her age, frailty and end stage dementia, taken together with the trauma sustained as a result of falls and corrective surgery. Professor Black agreed that the analgesics and sedatives had also made a contribution to her death (p11).

James Mehigan, Counsel instructed on behalf of Mrs Mackenzie, made submissions inviting the Coroner to consider a narrative verdict incorporating the following questions: whether the management of Mrs Richards’ medical condition at the hospital was appropriate; whether the administration and dosage of painkilling and sedative drugs was appropriate; and, if the answer to either of those questions was ‘no’, whether such inappropriate actions caused or contributed more than minimally, negligibly or trivially to Mrs Richards’ death. The Coroner was also invited to consider a verdict of unlawful killing or, as an alternative, a verdict of neglect (PCO001662).

On 17 April 2013, Mr Horsley returned a narrative verdict in the following terms:

Following the Coroner’s verdict, Mrs O’Brien stated that she was “disappointed after all of this time” by the verdict (SOH100666, p1). Mrs Mackenzie also criticised the verdict, saying that it was “extraordinary” that the Coroner found her mother to be in the end stages of dementia (FAM001101). John White of Blake Lapthorn, who represented Mrs Mackenzie, expressed the view that the outcome was “weakly positive” and that while it was “fundamental to be able to show that the prescribing was a significant contributory cause of death” – which Mr Horsley “did find ... on the balance of probabilities” – Mr White was disappointed “… that [Mr Horsley] did not feel able to venture any criticisms of Dr Barton and the nurses” (FAM101480, p1).

Julia Barton, Chief Quality Control Officer at the Fareham and Gosport Clinical Commissioning Group, offered her sympathies to Mrs Richards’ family and said that “any necessary action” would be taken following a review of the verdict, but “that lots had changed at the hospital since the late 1990s” (FAM001101, p1).