A public inquiry into the failings at Stafford Hospital has concluded that NHS staff should face prosecution if they are not open and honest about mistakes.
On 9 June 2010, the Secretary of State for Health, Andrew Lansley MP, announced a full public inquiry into the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire Foundation NHS Trust.
The final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry was published on Wednesday 6 February 2013.
The Chairman of the inquiry, Robert Francis QC, said that “fundamental change” was needed to prevent the public from losing confidence in the NHS. He has made 290 recommendations as a result of the inquiry.
Stafford Hospital Public Inquiry
The inquiry was held following years of abuse and neglect which led to the unnecessary deaths of hundreds of patients. Previous investigations have established the abuse and neglect that took place from 2005 to 2008 and this inquiry looked in more detail at why the system did not prevent the problems or detect them sooner.
Data relating to Stafford Hospital has shown that there were between 400 and 1,200 more deaths than would have been expected between 2005 and 2008, although it is impossible to say that all of these patients would have survived if they had received better treatment.
The levels of care that led to the needless deaths have already been documented in a 2009 report by the Healthcare Commission and an independent inquiry in 2010. Both criticised the cost-cutting and target-chasing culture at the Mid Staffordshire Trust which ran the hospital.
It was reported that receptionists were left to decide which patients to treat, inexperienced doctors were put in charge of critically ill patients and nurses were not trained in how to use vital equipment.
The inquiry identified numerous warning signs which could and should have alerted the system to the problems developing at the Trust. It found that the fact the warning signs did not alert the system to the problems had a number of causes, including:
- A culture focused on doing the system’s business – not that of the patients.
- An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern.
- Standards and methods of measuring compliance which did not focus on the effect of a service on patients.
- Too great a degree of tolerance of poor standards and of risk to patients.
- Failure of communication between the many agencies to share their knowledge of concerns.
- Assumptions that monitoring, performance management or intervention was the responsibility of someone else.
The inquiry said that the changes required did not need further reform. Instead, it urged everyone from “porters and cleaners to the secretary of state” to work together to shift the culture. The recommendations included:
- The merger of the regulation of care into one body rather than 2.
- Senior managers to be given a code of conduct and the ability to disqualify them if they are not fit to hold such positions.
- Hiding information about poor care to become a criminal offence.
- A statutory obligation on doctors and nurses for a duty of candour so they are open with patients about mistakes.
- An increased focus on compassion in the recruitment, training and education of nurses.
Mr Francis was reported as saying:
“This is a story of appalling and unnecessary suffering of hundreds of people. They were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.
“I have today made 290 recommendations designed to change this culture and make sure that patients come first. We need a patient-centred culture, no tolerance of non-compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership, caring compassionate nursing, and useful and accurate information about services.”
This public inquiry has focused only on Stafford Hospital, but there is concern in the wider NHS about basic standards of care.
Comment
When patients are admitted to hospital, they are at their most vulnerable and have little choice but to put their faith and trust into the system. It is sad to hear such shocking stories of neglect, abuse and deaths which could and should have been avoided and it is little wonder that public confidence in the NHS is deteriorating.
The public inquiry was a necessary step to assess what went so terribly wrong at this Trust. There are clearly lessons to be learnt and significant changes to be made to ensure that the standard of care is improved throughout the NHS as a whole.
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