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My mother, Elsie Devine, had never had pain and never taken so much as a paracetamol she was in Gosport for transition to come home after discharge for UTI in the Q.A. Hospital. Unfortunately all the family were in Hammersmith Hospital where my husband was undergoing a bone-marrow transplant and no one was at home where she lived with us. At 9am on 18 November 1999, Dr Joanne Taylor recorded her as “happy, no complaints not ^obviously^paranoid”. Just 15 minutes later, a 25mcg fentanyl patch was applied under Elsie clothes unbeknownst to Elsie and her family. Dr Taylor’s crucial documented assessment was withheld from our family for eight years. We discovered it only through our own tenacity, meticulously searching a different medical file passed to us for Elsie’s inquest. A medical file we had never previously seen and even then this was not her complete original file. More evidence through our own persistence came available in 2023. Why, then, did the Gosport Independent Panel omit Dr Taylor’s note from Elsie’s case study portraying her with the hearsay from Dr Barton. Why was evidence that described her condition immediately before fentanyl was administered left out? These questions still demand answers 1999-2026 #VictimsOfGosport

Professor Baker Report was completed in October 2003 but not placed in the public domain until 2 August 2013—almost ten years later. Its findings were deeply disturbing. Of the 81 Gosport patients sampled, 76 had received an opiate before death and 72 had received diamorphine. Opiates were used across a wide range of conditions, frequently prescribed in advance and, in some cases, administered without evidence of a careful assessment or the recognised stepped approach to pain relief. Professor Baker concluded that an “almost routine use of opiates before death” had developed at Gosport and that this practice had “almost certainly” shortened the lives of some patients. He recommended that investigations into individual deaths should continue because his findings reinforced concerns about what may have occurred. Families were left without this crucial report for almost a decade. Why was evidence of such gravity kept from those whose relatives had died? Baker also recommended obtaining the working rota of Dr Barton and her GP partners to examine patterns of death more closely. Yet no resulting rota analysis, or full practice-level investigation at Forton Medical Centre has ever been disclosed. Why was this crucial line of investigation not pursued, and who decided it should go no further? #VictimsOfGosport 15th investigation into the investigations 1998-26 families wait justice.