Where is Gosport War Memorial Hospital, what happened there and what did the report find?
The inquiry has unearthed an astonishing catalogue of failure, arrogance and indifference from medical staff, health officials, local politicians and the police
FAMILIES are calling for justice after up to 656 patients at a Hampshire hospital died from lethal painkiller doses under Dr Jane Barton's care.
A new report has found that there was a "disregard for human life" and a "culture of shortening the lives" at Gosport War Memorial Hospital — here's all you need to know.
Where is Gosport War Memorial Hospital?
The hospital is located in the town of Gosport, on the south coast of Hampshire
It's situated on a pensinsula on the western side of Portsmouth Harbour, opposite the city of Portsmouth, which it's linked to by a ferry.
What happened there?
Dr Jane Barton oversaw the deaths of 656 patients from lethal painkiller doses — more than double the number murdered by Dr Harold Shipman.
Dr Barton, 69, worked at the community hospital in Gosport, Hampshire, between 1988 and 2000.
While there she signed 833 death certificates that have been investigated by an independent government panel.
Barton - dubbed Dr Opiate - prescribed deadly doses of medical heroin diamorphine to elderly patients.
Diamorphine was the painkiller used by Harold Shipman to murder his estimated 260 victims.
There were so many deaths on her watch that the two wards she ran at the community hospital became known as "the end of the line".
Dr Barton was found guilty over 11 deaths of “multiple instances of serious professional misconduct” by the General Medical Council in 2010.
The GMC had been told of her “brusque and indifferent” manner, "intransigence and worrying lack of insight" and "failure to recognise the limits of her professional competence".
But she wasn't sacked over her conduct and instead retired from medicine after the findings.
And in 2009, an inquest into 10 deaths at the hospital found that in five cases the administration of medication "contributed more than minimally".
It found that the skills of non-consultant doctors “particularly Dr Barton, were not adequate”.
There is no suggestion Barton deliberately took the lives of her patients.
She told how she and other medics at the hospital were under "unreasonable" pressure.
At the 2010 GMC hearing Dr Barton said she did not want her patients to suffer and insisted she always acted in their interests.
In 2002 her husband Tim told The Sunday Times: "Instead of trying to find a new Harold Shipman, it might be more constructive to ask why a part-time GP was looking after 48 beds".
Speaking at her home in Alverstoke, Hamps, Dr Barton said: "I don't know what will be in the report, but I don't think it will be very pleasant.
"I've never spoken to the Press about what happened and I don't plan to now."
What did the report find?
The £13million Gosport Independent Panel began in 2014 and was led by James Jones, the former Bishop of Liverpool who chaired the Hillsborough inquiry.
It reviewed a million pieces of evidence, spoke to families and looked for records of 2,000 patients who died at the hospital between 1987 and 2001 – though a quarter of these were missing.
It has focused on “unanswered questions” from earlier investigations into the hospital and Dr Barton which did not lead to any prosecutions.
It found 456 patients had their lives shorted after being given deadly doses of painkillers.
The 370-page report, published on June 20, 2018, said that given missing medical records as many as 200 more - 650 in total - may have suffered a similar fate during Barton's time at the hospital.
There was an “institutionalised regime” of prescribing and administering opioids without medical justification, it added.
Families who have campaigend for 20 years to have their loved ones’ deaths investigated were “marginalised” by hospital staff when they complained.
The report also found they were “failed” by the police and medical regulators who did not act or investigate thoroughly.
Early in Dr Barton’s tenure, nurses did raise concerns about the prescribing of diamorphine – the medical name for heroin – in 1991 and 1992 - but their calls went unheeded.
The report found that the "significant systemic problems" were missed after the previous investigation into Dr Barton.
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What will happen now after the inquiry's findings were published?
Health Secretary Jeremy Hunt told MPs police and the Crown Prosecution Service (CPS) would examine material in the report to consider their next steps and "whether criminal charges should now be brought".
Speaking in the Commons, Mr Hunt asked why it had taken 10 years for this to be made public.
Grieving families have called for "criminal proceedings" if individuals are held responsible.
The family of former naval officer Stan Carby, who was just 65 when he died within 24 hours of being admitted for rehabilitation following a series of mini-strokes, called for a full police probe into Dr Barton's actions.
His daughter, Cindy Grant, said: "The police never conducted a proper investigation into our allegations and it is time they looked at bringing criminal proceedings against those responsible.
"I think they ought to immediately look again at the case of Dr Jane Barton under whose care so many died."
Bishop Jones, who also headed the Hillsborough Inquiry, said: "It's not for the panel to ascribe criminal or civil liability.
"It will be for any future judicial processes to determine whatever culpability and criticism might be forthcoming."