The so called “Dr Opiate” and failings of numerous organisations to investigate hundreds of deaths.

The inquiry is being led by the former Bishop of Liverpool, James Jones, who also led the Hillsborough inquiry. Allegations date back to the late 1980s where patients were allegedly given opiates and other painkillers in very high doses leading to their deaths. In particular the actions of former GP, Dr Jane Barton, have been closely investigated.

Why has this all taken so long?

Concerns were first raised by Mrs Mackenzie in 1998 after her 91 year old mother died suddenly after being admitted to Gosport Hospital. Her concerns were not properly investigated by the authorities.

More families started to come forward and in 2002, Dr Barton was investigated regarding the deaths of 92 patients. However the Crown Prosecution Service decided in 2006 there was insufficient evidence to take the criminal case any further.

In 2009, a jury inquest found Dr Barton prescribed drugs that contributed to the deaths of Elsie Devine (88 years old), Elsie Lavender (83 years old), Robert Wilson (74 years old), Brian Cunningham (79 years old), and Geoffrey Packman (68 years old).

In 2010, Dr Barton was found guilty of misconduct by the GMC, however never struck off (she subsequently retired).

In 2014, the Department of Health concluded a 10 year investigation known as the “Barker Report” which found “remarkably high” painkillers were used. Shortly after this, over 20 years after the allegations were first reported, the then Health Minister set up an Independent Panel and announced a formal inquiry.

The Barker Report took over 10 years to complete. Primarily this was to allow inquests to be held. Whilst I take the point this is necessary, I am critical of the length of time the coronial system takes in general, even with complicated inquests such as these. I am also critical of the fact that certain evidence was not put to the jury such as fears by the former Commission for Health over improvements, a Hampshire Police briefing revealing a “failure of trust systems”, or an audit carried out by Professor Barker. I suspect these documents were omitted as they apportioned blame, and of course this is outside the very narrow remit of an inquest. That being said, all available evidence must be scrutinised to ensure transparency and I fear this made the inquest very much expert-biased.

What is the inquiry likely to conclude?

It is widely reported the inquiry is expected to find Dr Barton prescribed fatal overdoses of opiate pain killers which contributed to many patient deaths.

Unfortunately, the inquiry remit is fairly limited and I suspect it is unlikely to push for further criminal investigations or prosecutions. The offence of gross negligence manslaughter rightly has an exceptionally high threshold to prove and merely “contributing” to a death will not be sufficient. In these situations, families can pursue civil claims which has a lower burden of proof but these rarely hold individuals to account. They can bring about system changes (although not always), but primarily a civil claim will only provide a family with monetary compensation and I suspect that is not these families aim, particularly after so many years of campaigning.

I do hope this inquiry will answer the “unanswered questions” left by previous investigations. I however suspect families will be left feeling as though justice has not been done and those responsible, such as Dr Barton, have still not been held fully accountable. If one lesson can be learned, it should be to have a robust mechanism in place for investigating family concerns as soon as they are raised. This should include a fully transparent inquest held as soon as practicable after the death.

I await the findings and hope these families finally have some conclusions to their lengthy battle for answers.