Gosport Independent Panel: Publication of Report

Jonathan Ashworth Excerpts

Wednesday 20th June 2018 Commons Chamber

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

I thank the Secretary of State for the advance copy of his statement. I welcome the tone of his remarks and the apology that he has offered on behalf of the Government and the national health service.

This is a devastating, shocking and heartbreaking report. Our thoughts must be with the families of the 456 patients whose lives were shortened. I, like the Secretary of State, pay tribute to the right hon. Member for North Norfolk (Norman Lamb), whose persistence in establishing this inquiry in the face of a bureaucracy that, in his own words, attempted to close ranks, must be applauded. I know that other Members have also played an important part, including the hon. Member for Eastbourne (Stephen Lloyd), who is in his place, and the Minister for Care, who is understandably and properly in her Gosport constituency this afternoon. I also thank all those who served on the inquiry panel, and offer particular thanks for the extraordinary dedication, calm, compassionate, relentless and determined leadership—yet again—of the former Bishop of Liverpool, James Jones, in uncovering an injustice and revealing a truth about a shameful episode in our nation’s recent history.

As the Secretary of State quoted, the Right Rev. James Jones said:

“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.”

That trust was betrayed. He continued:

“whereas a large number of patients and their relatives understood that their admission to the hospital was for either rehabilitation or respite care, they were, in effect, put on a terminal care pathway.”

Others will come to their own judgment, but for me that is unforgivable.

This is a substantial, 400-page report that was only published in the last hour or so, and it will take some time for the House to fully absorb each and every detail, but let me offer a few reflections and ask a few questions of the Secretary of State. Like the Secretary of State, the question that lingers in my mind is, how could this have been allowed to go on for so long? How could so many warnings go unheeded?

The report is clear that concerns were first raised by a nurse in 1991. The hospital chose not to rectify the practice of prescribing the drugs involved. Concerns were raised at a national level, and the report runs through a complicated set of back and forths between different versions of health trusts and successor health trusts, management bodies and national bodies about what to do and what sort of inquiry would be appropriate. An inquiry was eventually conducted and it found an

“almost routine use of opiates”

that

“almost certainly shortened the lives of some patients”.

It seems that that report was left on a shelf, gathering dust.

I am sure that many of the officials and players acted in good faith but, taken as a whole, there was a systemic failure properly to investigate what went wrong and to rectify the situation. In the words of the report, serious allegations were handled

“in a way that limits the impact on the organisation and its perceived reputation.”

The consequence of that failure was devastating.

To this day, the NHS landscape understandably remains complex and is often fragmented. How confident is the Secretary of State that similar failures—if, God forbid, they were to happen again somewhere—would be more easily rectified in the future? Equally, as the Secretary of State recognises, there are questions about Hampshire constabulary. As the report says,

“the quality of the police investigations was consistently poor.”

Why is it that the police investigated the deaths of 92 patients, yet no prosecutions were brought? The report has only just been published, but what early discussions will the Secretary of State be having with the Home Secretary to ensure that police constabularies are equipped to carry out investigations of this nature, if anything so devastating were to happen anywhere else?

What about the voice of the families? Why did families who had lost loved ones have to take on such a burden and a toll to demand answers? It is clear that the concerns of families were often too readily dismissed and treated as irritants. It is shameful. No family should be put through that. I recognise that the Secretary of State has done work on this in the past and I genuinely pay tribute to him, but how can he ensure that the family voice is heard fully in future? He is right that we must be cautious in our remarks today, but can he give me the reassurance that all the relevant authorities will properly investigate and take this further? If there is a police investigation, can he guarantee that a different force will carry it out?

I also want the Secretary of State to give us some more general reassurances. Is he satisfied that the oversight of medicines in the NHS is now tight enough that incidents such as this could never be allowed to happen again? What wider lessons are there for patient safety in the NHS? Is additional legislation now required? Does he see a need for any tightening of the draft Health Service Safety Investigations Bill to reflect the learnings from this case?

The Right Rev. James Jones has provided a serious, devastating, far-reaching service in a far-reaching report. Aggrieved families have had to suffer the most terrible injustice. In the next few weeks, we will rightly acknowledge 70 years of our national health service. The Secretary of State is right to say that this must not cast a shadow over the extraordinary work done every day by health professionals in our NHS. But on this occasion, the system has let so many down. We must ask ourselves why that was allowed to happen and dedicate ourselves to ensuring that it never happens again.

[Mr Hunt]

I thank the shadow Health Secretary for the considered tone of his comments. I agree with everything he says. Members across the House will understand that we are all constrained in what we can say about the individual doctor concerned—because that is now a matter for the police and the CPS to take forward—but we are not constrained in debating what system lessons can be learned, and we should debate them fully, not just today but in the future. The big question for us is not so much, “How could this have happened once?”—because in a huge healthcare system we are, unfortunately, always occasionally going to get things that go wrong, however horrific that sometimes is—but, “How could it have been allowed to go on for so long without being stopped?”

Reflecting the hon. Gentleman’s comments, the poor treatment of whistleblowers, the ignoring of families and the closing of ranks is wrong, and we must stop it. We must go further than we have gone to date. In a way, though, it is straightforward, because we know exactly what the problem is and we just have to make sure that the culture changes. The more difficult bit is where there were process issues that happened in good faith but had a terrible outcome.

In particular, this report is a salutary lesson about the importance of transparency. Obviously I had only a couple of hours to read it—so not very long—but it looks as though the Baker report was left to gather dust for 10 years, for the perfectly straightforward and understandable reason that people said that it could not be published in the course of a police investigation or while an inquest was going on. I am speculating here, but I am pretty certain that had it been published, transparency would have prompted much more rapid action, and some of the things that we may now decide to do we would have done much, much earlier. That is an incredibly powerful argument for the transparency that has sadly been lacking.

How confident can I be that this would not happen again? I do think that the culture is changing in the NHS, that the NHS is more transparent and more open, and that interactions with families are much better than they were. However, I do not, by any means, think that we are there yet. I think that we will uncover from this a number of things that we are still not getting right.

As the hon. Gentleman will understand, it is not a decision for the Government as to which police force conducts these investigations. We have separation of powers and that has to be a matter for the police. One of the things that we have to ask about police investigations is whether forces have access to the expertise they need to decide whether they should prioritise an investigation. When the medical establishment closes ranks, it can be difficult for the police to know whether they should challenge that, and it does appear that that happened in this case.

In terms of wider lessons on the oversight of medicines and the Health Service Safety Investigations Bill, we will certainly take on board whether any changes need to be made there.