Gosport Independent Panel: Publication of Report — House of Commons, 2018-06-20
Topic: Health
Jeremy Richard Streynsham Hunt (Conservative, Centre-right): This morning, the Gosport Independent Panel published its report on what happened at Gosport Memorial Hospital between 1987 and 2001. Its findings can only be described as truly shocking. The panel found that, over the period, the lives of more than 450 patients were shortened by clinically inappropriate use of opioid analgesics, with an additional 200 lives also likely to have been shortened if missing medical records are taken into account The first concerns were raised by brave nurse whistleblowers in 1991, but then systematically ignored. Families first raised concerns in 1998 and they, too, were ignored. In short, there was a catalogue of failings by the local NHS, Hampshire constabulary, the General Medical Council, the Nursing and Midwifery Council, the coroners and, as steward of the system, the Department of Health Nothing I say today will lessen the anguish and pain of families who have campaigned for 20 years for justice after the loss of a loved one. But I can at least, on behalf of the Government and the NHS, apologise for what happened and what they have been through. Had the establishment listened when junior NHS staff spoke out, and had the establishment listened when ordinary families raised concerns instead of treating them as "troublemakers", many of those deaths would not have happened I pay tribute to those families for their courage and determination to find the truth. As Bishop James Jones, who led the panel, says in his introduction: "what has to be recognised by those who head up our public institutions is how difficult it is for ordinary people to challenge the closing of ranks of those who hold power...it is a lonely place seeking answers that others wish you were not asking." I also thank Bishop Jones and his panel for their extremely thorough and often harrowing work. I particularly want to thank the right hon. Member for North Norfolk (Norman Lamb), who, as my Minister of State in 2013, came to me and asked me to overturn the official advice he had received that there should not be an independent panel. I accepted his advice and can say today that, without his campaigning in and out of office, justice would have been denied to hundreds of families In order to maintain trust with the families, the panel followed a "families first" approach in its work, which meant that the families were shown the report before it was presented to Parliament. I, too, saw it for the first time only this morning, so today is an initial response and the Government will bring forward a more considered response in the autumn That response will need to consider the answers to some very important questions. Why was the Baker report, completed in 2003, only able to be published 10 years later? The clear advice was given that it could not be published during police investigations and while inquests were being concluded, but can it be right for our system to have to wait 10 years before learning critically important lessons that could save the lives of other patients? Likewise, why did the GMC and NMC, the regulators with responsibility for keeping the public safe from rogue practice, take so long? The doctor principally involved was found guilty of serious professional misconduct in 2010, but why was there a 10-year delay before her actions were considered by a fitness to practise panel? While the incidents seemed to involve one doctor in particular, why was the practice not stopped by supervising consultants or nurses who would have known from their professional training that these doses were wrong Why did Hampshire constabulary conduct investigations that the report says were "limited in their depth and range of offences pursued", and why did the Crown Prosecution Service not consider corporate liability and health and safety offences? Why did the coroner and assistant deputy coroner take nearly two years to proceed with inquests after the CPS had decided not to prosecute? Finally and more broadly, was there an institutional desire to blame the issues on one rogue doctor rather than to examine systemic failings that prevented issues from being picked up and dealt with quickly, driven, as the report suggests it may have been, by a desire to protect organisational reputations I want to reassure the public that important changes have taken place since these events that would make the catalogue of failures listed in the report less likely. These include the work of the Care Quality Commission as an independent inspectorate with a strong focus on patient safety, the introduction of the duty of candour and the learning from deaths programme, and the establishment of medical examiners across NHS hospitals from next April. But today’s report shows that we still need to ask ourselves searching questions as to whether we have got everything right. We will do that as thoroughly and quickly as possible when we come back to the House with our full response Families will want to know what happens next. I hope that they and hon. Members will understand the need to avoid making any statement that could prejudice the pursuit of justice. The police, working with the Crown Prosecution Service and clinicians as necessary, will now carefully examine the new material in the report before determining their next steps, in particular whether criminal charges should now be brought. In my own mind, I am clear that any further action by the relevant criminal justice and health authorities must be thorough, transparent and independent of any organisation that may have an institutional vested interest in the outcome. For that reason, Hampshire constabulary will want to consider carefully whether further police investigations should be undertaken by another police force My Department will provide support for families from today, as the panel’s work has now concluded, and I intend to meet as many of the families as I can before we give our detailed response in the autumn. I am also delighted that Bishop James Jones has agreed to continue to provide a link to the families, and to lead a meeting with them in October to allow them to understand progress on the agenda and any further processes that follow the report. I commend the role played by the current MP for the area, my hon. Friend the Member for Gosport (Caroline Dinenage), who campaigned tirelessly for an independent inquiry and is unable to be here today because she is with the affected families in Portsmouth. For others who are reading about what happened and have concerns that it may also have affected their loved ones, we have put in place a helpline. The number is available on the Gosport Independent Panel website and the Department of Health and Social Care website. We are putting in place counselling provision for those affected by the tragic events and who would find it helpful Let me finish by quoting again from Bishop Jones’s foreword to the report. He talks powerfully about the sense of betrayal felt by families: "Handing over a loved one to a hospital, to doctors and nurses, is an act of trust and you take for granted that they will always do that which is best for the one you love." Today’s report will shake that trust, but we should not allow it to cast a shadow over the remarkable dedication of the vast majority of people working incredibly hard on the NHS frontline. Working with those professionals, the Government will leave no stone unturned to restore that trust. I commend this statement to the House.