the report is here
https://www.gosportpanel.independent.gov.uk/media/documents/070618_CCS207_CCS03183220761_Gosport_Inquiry_Whole_Document.pdf
all four hundred pages
various points arise - no witnesses were called ( I think - I got a bit tired reading it towards the end) and so it was a paper only
very patient oriented - well victim centric - so their voices were heard. I have had a day in court with a victim who was giving the doctors hell, and at the end of the day (£10 000 per day) a QC said: "we know the meeting occurred but the doctor you say was there, we can show was in Saudi at that time"
The hospital changed into a Trust half way thro - and Mr Samuel picked up the old hospital's management board minutes out of secure storage - and lost them! The contents list of the lost documents clearly state what was in them
Like Dame janet smith and shipman - where the Pontefract notes were lost - the God Bishop cheerily said - well I will tack on an extra 200 deaths will that do?
They get a professor ( having searched around for one who had actually stepped inside a cottage hospital once or twice doing rehab ) to say Morphine should only be used as an analgesic. Everyone knows it has a sedative action and drug addicts certainly arent taking it to kill the pain in their lives
Pt A is 91 ( yup) and described as completely independent -but has fallen over and broken a hip. Then post op she falls over again. and later dies. Does anyone realise what the mortality of hip fracture is in 90 y olds at one month ? The books put it at 10% - I would say more like 30%. The hip is meant to break before they fall over by the way.
So it worth a read - but shipman ( yup he gets a good mench ) she certainly isnt
This will herald a " oh no|! we cant give morphine !" famine on the wards by the way - or as an Irish doctor quipped ( heroin not allowed in Dublin ) the only place you can get heroin now is in the hospital car park .....