A four-year inquiry into the deaths of hundreds of elderly people who were routinely prescribed opioid drugs is expected to say that blame lies not just with the doctor involved but also those who worked with her, failed to monitor her and who failed to investigate – including the government.

The inquiry was launched following a police investigation into the deaths of 92 patients of Dr Jane Barton at the Gosport War Memorial hospital in the late 1990s. No charges were brought but inquests held in 2009 and 2013 found that medication prescribed by Barton had contributed to the deaths of six patients.

The report, led by Bishop James Jones – who ran the Hillsborough inquiry, is likely to make a wide range of recommendations and to criticise the government, which sat on a damning report into what happened for a decade. It is understood that Theresa May will reference the findings at prime minister’s questions in the House of Commons on Wednesday.

But the families that campaigned for many years to find out what happened to their loved ones and hold those responsible to account are unlikely to get what they have always wanted – criminal prosecutions.

An investigation by the doctors’ regulatory body, the General Medical Council (GMC), ruled in 2009 that Barton had overprescribed painkilling opiates to a number of her patients. It found her guilty of serious professional misconduct, having made multiple errors, including failing to keep up to date, refer patients to other doctors, tell colleagues what she was doing or keep notes. But the panel allowed her to continue practising as a GP under strict conditions.

She then retired, requesting voluntary erasure from the medical register. The inquiry is not expected to press for any criminal investigation or refer anything to the police as this is reportedly outside the remit. There is no suggestion that Barton is guilty of murder.



The Jones inquiry has looked at more than 800 death certificates that she signed. But its criticism is likely to go well beyond the doctor, who said she did the best she could for her patients in a hospital that was understaffed and under pressure, with too many referrals to the wards where she worked.

Dr Jane Barton Photograph: Chris Ison/PA

A review by Richard Baker of the University of Leicester, commissioned by the then chief medical officer Prof Liam Donaldson in 2003, was damning, but the department of health refused to publish it until 2013. It found “a practice of almost routine use of opiates before death” on the hospital’s Dryad ward, apparently authorised by the words in patient’s notes, “please make comfortable”.

He said this could have gone back as far as 1988 and could have preceded Barton’s tenure at the hospital. “The practice almost certainly had shortened the lives of some patients, and it cannot be ruled out that a small number of these would otherwise have been eventually discharged from hospital alive,” said his report.

The GMC said the decision of its disciplinary panel not to strike Barton off the medical register in 2009 was wrong. It issued a statement at the time saying it disagreed with the panel, but it did not then have the power to appeal against the decision. That has now changed.

The Gosport War Memorial Hospital Photograph: Chris Ison/PA

Peter Walsh, the chief executive of campaign group Action Against Medical Accidents, which helped the families get inquests held and pressed for an inquiry said: “There are questions to be asked that are relevant today, including why it has taken so long to open up the can of worms. The families need closure. I’m hoping they get something close to closure.

“The Department of Health will say it was so long ago and things have changed, but I’m not so sure – particularly if you look at nursing homes.

“There are big concerns about using sedatives and drugs like diamorphine in nursing homes and very lacklustre monitoring of prescribing. There have been serious errors in overdosing with diamorphine and inappropriate prescribing of it.

“While things have tightened up in particular in the hospital setting where you hope you can’t get a rogue doctor carrying on like Barton did, in nursing homes it is less rigorous.

“There are lessons above all to be learned about transparency,” he said. “I’m really hoping they get to the bottom of how government and its institutions contributed to what probably could be described as a cover-up.”