Wednesday, 6 February 2013

Francis Inquiry – Key conclusions and links

Robert Francis QC has today published his findings after a 31-month public inquiry costing £13 million into why up to 1,200 patients died needlessly in Stafford between 2005 and 2009.


Final report
Executive summary
BBC Live report
BBC Report
BMA responses

Francis said it would be ‘dangerous’ to blame ‘a single rogue healthcare professional’ for what went wrong. His 1,782-page report contains 290 recommendations.

The Telegraph reports as follows:

(Francis) said of the scandal: ‘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. Patients were let down by the Mid Staffordshire NHS Foundation Trust. There was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed, and fundamental rights to dignity were not respected.’

The evidence of more than 250 witnesses and more than a million pages of documentary evidence showed that elderly and vulnerable patients were left unwashed, unfed and without fluids, said Mr Francis. Some patients had to relieve themselves in their beds when they got no help to go to the bathroom, others were left in excrement-stained sheets and had to endure ‘filthy conditions’ onwards.

In a letter to the Health Secretary, Jeremy Hunt, accompanying the report, Mr Francis said hospitals must put patients first, ensure ‘openness, transparency and candour’ throughout the NHS when concerns are raised and ensure proper accountability for what staff do.

He said the scandal happened because board members and other leaders within the Trust ‘failed to appreciate the enormity of what was happening, and reacted too slowly, if at all’.
He says ‘routine neglect’ became the norm because of a culture of ‘fear, bullying and secrecy’.

The Trust had a culture of ‘self promotion rather than critical analysis’ and consultants ‘did not pursue management with any vigour’ about concerns they had and in many cases ‘kept their heads down’’

The Trust focused on finances rather than patient needs, he said, and ‘squabbling’ between local patient groups such as community health councils meant that “the public of Stafford were left with no effective voice...throughout the worst crisis any district general hospital in the NHS can ever have known’.

Francis’ full letter to the secretary of state is reproduced below:

Dear Secretary of State

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry

As you know, I was appointed by your predecessor to chair a public inquiry under the Inquiries Act 2005 into the serious failings at the Mid Staffordshire NHS Foundation Trust. Under the Terms of Reference of the Inquiry, I now submit to you the final report.

Building on the report of the first inquiry, the story it tells is first and foremost of appalling suffering of many patients. This was primarily caused by a serious failure on the part of a provider Trust Board.

It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care.

The story would be bad enough if it ended there, but it did not. The NHS system includes many checks and balances which should have prevented serious systemic failure of this sort. There were and are a plethora of agencies, scrutiny groups, commissioners, regulators and professional bodies, all of whom might have been expected by patients and the public to detect and do something effective to remedy non-compliance with acceptable standards of care. For years that did not occur, and even after the start of the Healthcare Commission investigation, conducted because of the realisation that there was serious cause for concern, patients were, in my view, left at risk with inadequate intervention until after the completion of that investigation a year later. In short, a system which ought to have picked up and dealt with a deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system.

The report has identified numerous warning signs which cumulatively, or in some cases singly, could and should have alerted the system to the problems developing at the Trust. That they did not has a number of causes, among them:

•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 service on patients;
•Too great a degree of tolerance of poor standards and of risk to patients;
•A 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;
•A failure to tackle challenges to the building up of a positive culture, in nursing in particular but also within the medical profession;
•A failure to appreciate until recently the risk of disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation.

I have made a great many recommendations, no single one of which is on its own the solution to the many concerns identified. The essential aims of what I have suggested are to:

•Foster a common culture shared by all in the service of putting the patient first;
•Develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff, the breach of which should not be tolerated;
•Provide professionally endorsed and evidence-based means of compliance with these fundamental standards which can be understood and adopted by the staff who have to provide the service;
•Ensure openness, transparency and candour throughout the system about matters of concern;
•Ensure that the relentless focus of the healthcare regulator is on policing compliance with these standards;
•Make all those who provide care for patients – individuals and organisations – properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service;
•Provide for a proper degree of accountability for senior managers and leaders to place all with responsibility for protecting the interests of patients on a level playing field;
•Enhance the recruitment, education, training and support of all the key contributors to the provision of healthcare, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do;
•Develop and share ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system.

In introducing the first report, I said that it should be patients – not numbers – which counted. That remains my view. The demands for financial control, corporate governance, commissioning and regulatory systems are understandable and in many cases necessary. But it is not the system itself which will ensure that the patient is put first day in and day out. Any system should be capable of caring and delivering an acceptable level of care to each patient treated, but this report shows that this cannot be assumed to be happening.

The extent of the failure of the system shown in this report suggests that a fundamental culture change is needed. This does not require a root and branch reorganisation – the system has had many of those – but it requires changes which can largely be implemented within the system that has now been created by the new reforms. I hope that the recommendations in this report can contribute to that end and put patients where they are entitled to be – the first and foremost consideration of the system and everyone who works in it.

Yours sincerely

Robert Francis QC
Inquiry Chairman

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