THE unprecedented inquest into ten deaths at the Gosport War Memorial Hospital (GWMH) follows a series of inquiries by police and the NHS into almost 100 deaths dating back to the late 1990s.

In a rare move by Justice Secretary Jack Straw, the inquests were approved despite seven of the bodies being already cremated and a post-mortem examination being carried out on one of the patients.

Concern about care at the community hospital, run at the time by Portsmouth Healthcare NHS Trust, was first raised by Gillian Mackenzie, the daughter of a patient who died at GWMH.

She contacted police over her concerns that her mother, Gladys Richards, died because of unnecessarily high doses of morphine.

This case was not examined as one of the ten in this inquest but Mrs Mackenzie has been informed that a separate inquest will be heard into her mother's death at a future date.

Following publicity in local media in 1998 surrounding the police investigation into her mother's death, many more families came forward with similar concerns.

The police investigation was eventually expanded to cover the treatment of several patients at the hospital but it did not result in any criminal proceedings.

But detectives shared concerns about care at GWMH with the Commission for Health Improvement (CHI) in August 2001.

The CHI concluded that in the late 1990s there had been a failure in patient care, particularly in prescribing practices as well as in the supervision and appraisal of staff.

But the CHI also concluded that by the time of its investigation, which finished in 2002, the Fareham and Gosport Primary Care Trust (PCT) and East Hampshire PCT, which had taken over control of the hospital, had improved its systems and had implemented appropriate guidelines.

Publicity surrounding the announcement of the CHI's findings brought the issue to the attention of more families and Hampshire police started another investigation in September 2002 with a total of 92 deaths now being examined.

A sample ten cases were referred to the Crown Prosecution Service (CPS) but it concluded that there was insufficient evidence to prosecute with no realistic prospect of a conviction.

Following this decision, the police met with the General Medical Council (GMC), the Nursing and Midwifery Council (NMC) and the Portsmouth coroner.

This led to a meeting between the coroner and Jack Straw and approval for the ten separate inquests, which were held together because of over-lapping evidence.

Government chief medical officer Sir Liam Donaldson also commissioned a clinical audit to examine death rates at the hospital in September 2002.

Richard Baker, a professor of clinical governance who worked on the Shipman inquiry, was appointed to the task but his results have not been made public.

As a result of the series of investigations, not a single member of staff has been disciplined or charged.

A spokeswoman for NHS Hampshire, which is now responsible for GWMH, said: ''Two senior members of management were redeployed for six months while internal investigations took place.

''However, both internal investigations and the CHI review concluded that there was no evidence to suggest that any individual should be disciplined and the staff members returned to their substantive posts.''

Portsmouth and South East Hampshire deputy coroner Andrew Bradley, who has headed the month-long inquest, said the purpose of the hearing was to establish how each of the patients died and was not a ''finger-pointing'' exercise.