Relatives call for prosecutions over 'shocking' hospital death toll
Criminal charges could be brought following "truly shocking" revelations that more than 450 people had their lives shortened after being prescribed powerful painkillers at the Gosport War Memorial Hospital.
A damning report found an additional 200 patients were "probably" similarly administered with opioids between 1989 and 2000, without medical justification.
Health Secretary Jeremy Hunt said the Gosport Independent Panel had identified a "catalogue of failings" by the authorities and apologised to the families who lost loved ones in the scandal.
Relatives of elderly patients who died at the hospital branded the findings "chilling" and called for criminal prosecutions to be brought.
Mr Hunt told MPs: "The police, working with the CPS and clinicians as necessary, will now carefully examine the new material in the report before determining their next steps and in particular whether criminal charges should now be brought."
He said any further investigations should be carried out by organisations not involved in previous probes, suggesting that Hampshire Police should bring in another force.
The panel found that, over a 12-year period as clinical assistant, Dr Jane Barton was "responsible for the practice of prescribing which prevailed on the wards".
But Mr Hunt questioned whether there had been an "institutional desire" to blame the events on a "rogue doctor" to protect reputations rather than address systemic failings.
The panel said the case of GP Harold Shipman, who was jailed in 2000 for murdering 15 patients, had "cast a long shadow" over events at the hospital.
The perception that Dr Barton might be a "lone wolf" operating alone "rapidly took root", the report said.
Police did not pursue a "wider investigation" into what was going on at the hospital and instead focused on the actions of Dr Barton.
The inquiry, led by the former bishop of Liverpool, the Rt Rev James Jones, did not ascribe criminal or civil liability for the deaths.
Mr Hunt said the report's findings were "truly shocking", with whistleblowers and families ignored as they attempted to raise concerns.
"There was a catalogue of failings by the local NHS, Hampshire Constabulary, the GMC, the NMC, the coroners and, as steward of the system, the Department of Health," he told MPs.
"Had the establishment listened when junior NHS staff spoke out, had the establishment listened when ordinary families raised concerns instead of treating them as troublemakers, many of those deaths would not have happened."
At Prime Minister's Questions, Theresa May said: "The events at Gosport Memorial Hospital were tragic, they are deeply troubling and they brought unimaginable heartache to the families concerned."
Bridget Reeves, the granddaughter of 88-year-old Elsie Devine, said in a statement on behalf of the families: "This has been sinister, calculated and those implicated must now face the rigour of the criminal justice system.
"Accountability must take precedence here.
"These horrifying, shameful, unforgivable actions need to be disclosed in a criminal court for a jury to decide and only then can we put our loved ones to rest."
The Gosport Independent Panel found that hospital management, Hampshire Police, the Crown Prosecution Service (CPS), General Medical Council (GMC) and Nursing and Midwifery Council (NMC) "all failed to act in ways that would have better protected patients and relatives".
Its report also highlighted failings by healthcare organisations, local politicians and the coronial system.
The Gosport Independent Panel investigation into hundreds of suspicious deaths at the hospital, which was first launched in 2014, examined more than a million pages of documents.
It revealed "there was a disregard for human life and a culture of shortening lives of a large number of patients" at the Hampshire hospital.
The report added: "There was an institutionalised regime of prescribing and administering 'dangerous doses' of a hazardous combination of medication not clinically indicated or justified, with patients and relatives powerless in their relationship with professional staff."
Concerns were first raised by nurses in 1991 but these warnings went "unheeded".
When relatives later complained, from 1998, they were "consistently let down by those in authority, both individuals and institutions".
The report concludes: "The panel found evidence of opioid use without appropriate clinical indication in 456 patients.
"The panel concludes that, taking into account missing records, there were probably at least another 200 patients similarly affected but whose clinical notes were not found.
"The panel's analysis therefore demonstrates that the lives of over 450 people were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital, and that probably at least another 200 patients were similarly affected."
In 2010, the GMC ruled that Dr Barton, who has since retired, was guilty of multiple instances of professional misconduct relating to 12 patients who died at the hospital.
Several documents reviewed by the panel referred to the Shipman case.
However the Rt Rev Jones said events at the Gosport War Memorial Hospital were distinct, because they showed a "failure of the institution".
"It was the institution as well as individuals who it would seem to us were furthering this practice," he told a press conference.
Nurses on the ward were not responsible for the practice but did administer the drugs, including via syringe drivers, and failed to challenge prescribing, the panel said.
Consultants, though not directly involved in treating patients on the ward, "were aware" of how drugs were administered but "did not intervene to stop the practice".
Mr Hunt also questioned why consultants or nurses did not act to stop those involved.
He added: "Was there an institutional desire to blame the issues on one rogue doctor rather than examine systemic failings that prevented issues being picked up and dealt with quickly driven, as this report suggests it may have been, by a desire to protect organisational reputations?"
Hampshire Police chief constable Olivia Pinkney said: "Upon receiving the report earlier today, we said how important it was to take the time to properly digest the significance of what has been revealed.
"That remains the case but it is already apparent from our early reading of the 370 pages that in its deliberations, the Panel has had sight of information that has not previously been seen by Hampshire Constabulary.
"It is important that a process is put in place to ensure that all of the relevant agencies come together, to enable decisions about next steps to be made in a way that is well considered and transparent to all of the families."