In June this year, the Gosport Independent Panel published its report into what happened at Gosport War Memorial Hospital between 1987 and 2001. It found that 456 patients died sooner than they would have done after being given powerful opioid painkillers. As many as 200 other people may have had their lives shortened, but this could not be proved because medical records were missing.
The findings in the Gosport report are truly shocking, and we must not forget that every one of those people was a son or daughter, a mother or father, a sister or brother. I reiterate the profound and unambiguous apology on behalf of the Government and the NHS for the hurt and anguish that the families who lost loved ones have endured. These were not just preventable deaths, but deaths directly caused by the actions of others. The report is a deeply troubling account of people dying at the hands of those who were trusted to care for them. I pay tribute to the courage of the victims’ families and their local MP, my hon. Friend Caroline Dinenage, in their work for and commitment to the truth. Without their persistence, the catalogue of failures may never have come to light.
Along with the Prime Minister, I have met Bishop James Jones, who chaired the panel. He made it absolutely clear that what happened at Gosport continues to have an impact and places a terrible burden on relatives to this day. The failures were made worse because whistleblowers were not listened to, investigations fell short and lessons failed to be learnt. We must all learn the right lessons from the panel’s report and apply them across the entire system.
As Bishop Jones writes in the report, relatives felt betrayed by those in authority and were made to feel like “troublemakers” for asking legitimate questions. The report states that
“when relatives complained about the safety of patients…they were consistently let down by those in authority—both individuals and institutions. These included the senior management of the hospital, healthcare organisations, Hampshire Constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council and the Nursing and Midwifery Council.”
The panel heard how nurses raised concerns as far back as 1988, but were ignored and sidelined. More than 100 families raised concerns over more than two decades, but they were ignored and patronised. Frail, elderly people were seen as problems to be managed, rather than patients to be helped. Perhaps the most harrowing part of the report is when it makes clear that if action had been taken when problems were first raised, hundreds fewer would have died at Gosport. People want to see that justice is done, policies are changed and that we learn the right lessons across the NHS. I will take each of those in turn.
First, on justice, between 1998 and 2010, Hampshire Constabulary conducted three separate investigations. None of the investigations led to a prosecution. The panel criticised the police for their failings in the investigations and their failure to get to the truth. Families said that they felt police had not taken their concerns seriously enough or investigated fully. Because of Hampshire police’s failures, a different police force has been brought in. A new, external police team is now independently assessing the evidence and will decide whether to launch a full investigation. They must be allowed to complete that process and follow the evidence, so that justice is done. Much has improved in the NHS since the period covered by the panel’s report, but we cannot afford to be complacent. What happened at Gosport is both a warning and a challenge.
Let me turn to the reforms that have been made and the reforms that we plan to make. The Care Quality Commission has been established as an independent body that inspects all hospitals, GP surgeries and care homes to detect failings and identify what needs to be improved. We have set up the National Guardian’s Office to ensure that staff concerns are heard and addressed. Every NHS trust in England now has someone in place whom whistleblowers can speak to in confidence and without fear of being penalised. We have established NHS Improvement—a separate, dedicated organisation—to respond to failings and put things right, and the Healthcare Safety Investigation Branch now investigates safety breaches and uses them to learn lessons and spread best practice throughout the NHS.
Those are the reforms that the Government have already made, but we must go further, so motivated by this report we will bring forward new legislation that will compel NHS trusts to report annually on how concerns raised by staff have been addressed; and, we are working with our colleagues in the Department for Business, Energy and Industrial Strategy to see how we can strengthen protections for NHS whistleblowers, including changing the law and other options.
Next is the question of drug prescription. Central to the deaths at Gosport was the prescribing, dispensing and monitoring of controlled drugs. Since the period covered by the report, there have been significant changes in the way that controlled drugs are used and managed and these syringe drivers are no longer in use in the NHS. However, in the light of the panel’s findings, we are further reviewing how we can improve safety.
Further, from April next year, medical examiners will be introduced across England to ensure that every death is scrutinised by either a coroner or a medical examiner. Medical examiners are someone bereaved families can talk to about their concerns to ensure that investigations take place when necessary, to help to detect and deter criminal activity, and to promote good practice. The new system will be overseen by a new independent national medical examiner and training will take place to ensure a consistency of approach and a record of scrutiny.
The reforms that we have made since Gosport mean that staff can speak up with more confidence and that failings are identified earlier and responded to quicker. The reforms that we are making will mean greater transparency, stricter control of drugs and a full and thorough investigation of every hospital death. Taken together, they mean that warning signs about untypical patterns of death are more likely to be examined at the time, not 25 years later.
However, as well as these policy changes, there is a bigger change, too, which I turn to now. Just as with the reports into Mid Staffs and Morecambe Bay, the Gosport report will echo for years to come, and the culture change that these reports call for is as deep-rooted as it is vital. There has been a culture change within the NHS since Gosport, but the culture must change further still. One of the most important things that we learnt from the report is that we must create a culture where complaints are listened to and errors are learnt from, and that this must be embedded at every level in the NHS.
What happened at Gosport was not one individual error; it was a systemic failure to respond appropriately to terrible behaviour. To prevent that from happening again, we need to ensure that we respond appropriately to error—openly, honestly, taking concerns and complaints seriously and seeing them as an opportunity to learn and improve, not a need for cover-up and denial. I want to see a culture that starts by listening to patients and their relatives and by empowering staff to speak up. That starts with leaders creating a culture that is focused on learning not blaming—a culture that is less top-down and less hierarchical, with more autonomy for staff and which is more open to challenge and change. We need to see better leadership at every level in the NHS to create that culture across the NHS.
Today marks an important moment. Lessons have been learned, will be learned and must be applied. The voices of the vulnerable will be heard. Those with the courage to speak up will be celebrated. Leaders must change the culture to learn from errors, and we must redouble our resolve to create a health service that will be a fitting testament to the Gosport patients and their families. I commend this statement to the House.