By Dr Minh Alexander, NHS whistleblower and former consultant psychiatrist 24 November 2018
On Saturday 24 November 2018, Gosport families will protest outside Downing St.
The Gosport disaster is one of the most serious scandals in relation to the NHS, the rule of law and fundamental human rights.
In June 2018 the Gosport Independent Panel investigation concluded that at least 456 and possibly another 200 lives had been “shortened” by non-clinically indicated use of opiates at Gosport War Memorial Hospital. It also revealed that most of the deaths occurred after whistleblowers were ignored and mistreated. After the Panel reported, more families have reportedly come forward.
The man in the street might simply dispense with euphemisms such as “shortening of lives”, and speak plainly of killing. That was certainly the gist of internal correspondence between Norman Lamb Care Minister and Una O’Brien Permanent Secetary at the Department of Health and Social Care (DHSC), when referring to the “damning” findings of a report by Professor Richard Baker.
From correspondence 2 August 2013 between Norman Lamb and Una O’Brien:
The Baker report had been commissioned by the DHSC in 2002 but suppressed for ten years, whilst interminable and ultimately ineffective processes dragged out.
After the Baker report was finally published in 2013, the government commissioned the independent panel investigation, although some families had serious reservations about its terms of reference and ability to deliver the whole truth. Not all organisations that were later approached cooperated or provided information. Some of the documents supplied were heavily redacted. The panel did not test witnesses’ evidence by taking oral evidence.
When the panel’s investigation report was published in June 2018, all the many thousands of documents gathered, some repeatedly duplicated, were also published. But there was very limited indexing and organisation. The majority of documents are not listed in easily navigable format, and can only be found by speculative search. The families have been overwhelmed by this tsunami of data, which is effectively just another form of opacity, a snowstorm which obscures vital documents and details that did not appear in the panel’s final report.
In the same vein, Matt Hancock the Secretary of State made a statement in the House of Commons on 21 November 2018 without giving the families proper notice. He refused to meet with the families at this point, stating that upon the advice of Bishop James Jones who chaired the panel investigation, he would only do so at the conclusion of a police review. He made a rather vague promise to think about changing whistleblowing law, but not much else. In short, it was the usual government news management with which we are now so well accustomed.
The Gosport families are deeply dissatisfied with the government’s stance. Ann Reeves whose mother Elsie Devine perished at Gosport War Memorial Hospital, after deliberate administration of excess opiates without any clinical justification, comments:
“My mother was abused with controlled drugs. I have been informed by the Crown Prosecution Service that they intend to take no further action despite the findings of the Gosport Independent Panel Investigation. I believe the police have ample evidence for arrests but they only seek to delay further. Gosport families have been denied justice for over twenty years. We have repeatedly asked for a public inquiry. If we do not secure a police investigation, we will pursue a public inquiry. Our loved ones died in horrific circumstances. We deserve the full truth. This is a matter of huge importance to everyone. The State cannot be allowed to wash its hands of blood in this way, because then no one is safe”
I have started a search specifically for original witness statements to the police and other investigations, with the aim of collating the evidence on concerns about the practices at Gosport. This is not yet complete but a selection of witness statements which raise concerns about the care at Gosport is provided below, with links to the full statements on the website of the Gosport inquiry.
This post will be updated when the search is completed, and a spreadsheet of all witness statements found will be published here.
Many of the Gosport staff witness statements denied that there were problems with the administration of opiates or syringe drivers or any other issues of care.
But a minority of staff witness statements raised concerns about a range of issues.
Whistleblowers and others said they had concerns about the use of opiates.
One nurse thought that a patient was aware that her life was about to be ended, and reportedly asked “Why are you doing this to me?”
Another member of staff went as far as alleging that diamorphine made patients “quiet, shortened lives and was used to keep waiting lists down.
The witness statements revealed some staff who were not specifically acknowledged as whistleblowers by the Gosport Independent Panel report, but who had also raised concerns about poor care.
Institutionally abusive practices were alleged in some of the staff witness statements, such as getting patients out of bed and dressed in the small hours of the morning, threats and force feeding.
Some staff made general comments about insular, hierarchical and rigid culture. There was also a reference to serious understaffing.
There were also witness statements by family members and friends which raised concerns about very rapid and or unexpected deaths of loved ones, and specific concerns about the use of heavy sedative medication, opiates and syringe drivers.
One witness statement by a family member who said they had no concerns, but who described an unexpected rapid decline and death, is included for completeness.
(1) Witness statements of Gosport staff whistleblowers
Witness statement of Sylvia GIFFIN, nurse, document reference
HCO111239, 12 December 2012
Witness Statement of Shirley HALLMAN, nurse, document reference HCO110597, 28 July 2003
Witness statement of whistleblower Anita TUBBRITT, nurse, document reference HCO004127,21 October 2002
Witness statement of whistleblower Beverley TURNBULL, nurse, document reference HCO110797, 6 June 2005
Witness statement of Margaret WIGFALL, nurse, document reference HCO110869, 11 October 2002
(2) Other relevant Gosport staff witness statements:
Witness statement of Leslie ALDRIDGE, document reference
HCO111234, nurse, 6 May 2003
Witness statement of Carol BALL, nurse, document reference
HCO110569, 2 July 2003
Witness statement of Margaret BRENNAN, nurse and also daughter of a patient admitted to Gosport War Memorial Hospital, document reference HCO110609, 4 August 2003
Witness statement of Debra BROOKS, nurse, document reference
HCO110565, 24 June 2003
Witness statement of Deborah DAVIES, student nurse, document reference HCO004149, 29 April 2003
Witness statement of Isobel EVANS, matron, document reference HCO111031, 12 November 2002
Witness statement of Joan FORFAR, nursing assistant, document reference PCO000371, 24 April 2003
Witness statement of Linda GOLDIE, nurse, document reference HCO006236, 10 July 2003
Witness statement of Cecilia GREEN, nurse, document reference HCO111127, 29 August 2006
Witness statement of Elizabeth MEARS, nurse, document reference HCO004146, 18 August 2003
Witness statement of J MONDEY, nursing assistant, document reference HCO004159, 20 June 2003
Witness statement of Margaret PERRYMAN, nurse, document reference HCO110658, 18 August 2003
Witness statement of Pamela RIGG, nurse, document reference HCO111287, 6 June 2003
Witness statement of Joyce TEE, nursing assistant, document reference PCO000375, 22 July 2003
Witness statement of Valerie WEBB, nurse, document reference HCO004165, 15 August 2003
Witness statement of Geradine WITNEY, nurse tutor, document reference HCO111107, 10.12.2002
Witness statement of Betty WOODLAND, nurse and trade union rep, document reference HCO111170, 1 February 2003
(3) Witness statements by family members and friends expressing concerns:
Witness statement of June BAILEY, daughter of Jean STEVENS, document reference HCO110691, 16 April 2004
Witness statement of Dorothy BERESFORD, family friend of Geoffrey (Mick) PACKMAN, document reference HCO111103, 25 January 2006
Witness statement of Sandra BRIGGS, daughter in law of Elsie DEVINE, document reference PCO001175, 2 August 2004
Witness statement of Pamela BYRNE, step-daughter of Clifford HOUGHTON, document reference HCO110725, 4 August 2004
Witness statement of Keran EDWARDS daughter of Robert WILSON, document reference HCO110688, 7 April 2004
“I think it is possible that the staff gave him diamorphine because he asked to die and didn’t want to go home to his wife, for her to look after him”
Witness statement of Luci GREGORY, relative of Sheila GREGORY, document reference HCO004414, 2 June 2005
Witness statement of David HUNTINGTON, son of Robert WILSON, document reference, HCO004316 28 February 2005.
Witness statement of Carl JEWELL, nephew of Enid SPURGIN, document reference HCO110687, 17 March 2004
Witness statement of Jean KENNEDY, carer for Helena SERVICE, document reference HCO006813, 1.07.2004
Witness statement of Gillian KIMBLEY, wife of Robert WILSON, document reference HCO110697, 26 April 2004
Witness statement of Robert LOGAN, son of Robert WILSON, document reference HCO004319 , 6 March 2005
Witness statement of Tracy MULHOLLAND, granddaughter of Elsie DEVINE, document reference HCO110743 , 2 August 2004
Witness statement of Victoria PACKMAN, daughter of Geoffrey PACKMAN, document reference HCO111105, 18 January 2006
Witness statement of Lesley RICHARDS (previously LACK), daughter of Gladys RICHARDS, document reference FAM003527, 11 August 2004
Witness statement of James RIPLEY, patient, document reference HCO004189, 19 November 2002
Witness statement of Paule RIPLEY, wife of James RIPLEY, document reference HCO111095, 19 November 2002
Statement of Pauline ROBINSON, daughter of Ruby LAKE, document reference HCO110995, 21 July 2005
Witness statement of Shirley SELLWOOD, former carer of BRIAN CUNINGHAM, document reference HCO004212, 12 May 2004
Witness statement of Margaret SHERWIN, curate, about Michael PACKMAN, document reference HCO111102, 24 March 2006
Witness statement of Ernest STEVENS, husband of Jean STEVENS, document reference HCO110694, 16 April 2004
Witness statement of Florence TUFFEY, niece of Helena (Nelly) SERVICE, document reference, HCO110801 29 June 2004
On 30 November 2018 the Nursing Times reported that the government was obstructing the NMC’s access to “critical” evidence from the Gosport Independent Panel investigation that could bring some of the nurses to justice:
Nursing regulator in battle with government gatekeeper for Gosport nurse evidence
Expert report by Prof Brian Livesley on the death of Gladys RICHARDS at Gosport War Memorial Hospital
Whistleblowing in the NHS isn’t fixed yet, and this leaves patients exposed. An overview of unfinished policy business.
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