Page last updated at 14:55 GMT, Monday, 20 April 2009 15:55 UK

Unlawful killing claim sparked inquiry

By Anna Lindsay
BBC News

Gill MacKenzie
Gill MacKenzie says it is "grit and guts" that has got her this far

It was one allegation back in 1998 that triggered the whole process of questioning how some patients died at the Gosport War Memorial Hospital in Hampshire.

As a result, an inquest jury into 10 deaths found the administration of medication "contributed more than minimally" to five of the deaths, with three of those not receiving "appropriate" medication for their symptoms.

Gill MacKenzie suspected her 91-year-old mother, Gladys Richards, from Lee-on-Solent, had been unlawfully killed there and went to the police.

She believes her mother had been prescribed too much morphine.

"I rang the police and said I wanted to make an appointment to see somebody in CID with an allegation of unlawful killing," she told BBC South.

But Hampshire police disagreed with her assertion and, after investigating, no charges were brought.

She said their reaction at first was to "pat me on the head 'you've lost your mother'".

"But that wasn't what it was about at all," she said. "Never was."

But the publicity led other people, who were concerned about the circumstances in which their loved ones had died at the hospital, to come forward.

Seven of the 10 patients were - (clockwise from top left) - Sheila Gregory, Robert Wilson, Enid Spurgin, Geoffrey Packman, Elsie Devine, Arthur (Brian) Cunningham and Ruby Lake
The patients being looked at during the inquest died between 1996 and 1999

In total, concerns about 92 deaths at the hospital have been passed to Hampshire Constabulary since 1998 - but after investigating, no prosecutions were brought.

By 2001, police were looking at four more deaths to that of Gladys Richards - and a further two were brought to the attention of the NHS ombudsman.

"I was the only one who'd gone to the police you see and it wasn't until three years later when there was publicity that another 11 people [came forward]... then it got to 15, then it got to 20," Ms Mackenzie said.

Eventually officers decided to discontinue their inquiries.

Yet, throughout, police were "sufficiently concerned" about the care of older people at the hospital to alert England's independent healthcare regulator, the then Commission for Healthcare Improvement (CHI).

The CHI investigated and published a report in 2002 that was critical of the hospital and its then NHS trust - especially its lack of control in the prescription and use of diamorphine.

1998: Police investigate after Gladys Richards dies
1999: CPS decides insufficient evidence to prosecute
By 2001: Police look at four more deaths and a two others are brought to the attention of NHS ombudsman
2001: Police alert Commission for Healthcare Improvement (CHI)
Feb 2002: Police discontinue investigation
July 2002: CHI report criticises hospital's control in the prescription and use of diamorphine
Sept 2002: Third police investigation begins
July 2006: Police hand files into 10 deaths to CPS
Oct 2007: CPS says insufficient evidence to prosecute any staff
Early 2008: Police files passed to coroner
May 2008: Jury inquest opened and adjourned
March 2009: Jury inquest begins

There were "insufficient local prescribing guidelines in place governing the prescription of powerful pain relieving and sedative medicines", it said.

It also raised concerns that a "lack of a rigorous, routine review of pharmacy data led to high levels of prescribing on wards caring for older people not being questioned".

However, it concluded that by the time the report was published, the successor NHS trust had put adequate guidelines in place.

No-one was, or has been, disciplined in connection with the case.

The report generated further publicity, more families came forward, and a third police investigation began.

Ms MacKenzie said: "More people came forward and in the end the police had 90 people get in contact with them."

In the end, police files on 10 deaths were submitted to the Crown Prosecution Service (CPS) in 2006, but not one ended in a prosecution.

The families' campaign resulted in the Portsmouth and South East Coroner becoming involved, and in early 2008 he requested the police files and met with the Ministry of Justice (MoJ).

A decision to conduct inquests into the 10 deaths was taken and they were opened and adjourned in May 2008 - three of which were among the deaths raised prior to 2001.

Now, more than 11 years after Ms MacKenzie first raised suspicions, the jury at Portsmouth Coroners' Court has recorded narrative verdicts after a month-long inquest.

The Gosport War Memorial Hospital
The hospital is now run by a different NHS trust to the late 1990s

Ms MacKenzie attended every day of the inquests, even though her mother's death was not one of the final 10 to be heard.

It is due to be the subject of a separate inquest but a date has not yet been set.

She says she is pleased relatives' concerns have finally been aired publicly and that it is "grit and guts" that has got her to this point.

"The inquest I've been granted has not been due to the police putting my case forward," she said.

"It's been due to me being strong minded to make sure there was an inquest."

The General Medical Council and Nursing and Midwifery Council are also looking into the deaths, but many family members still want to see a public inquiry.

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