The report findings
The report highlights there were between 400 and 1,200 more patient deaths at Mid Staffordshire during the period 2005 to 2008 than would have been expected, although it is not possible to say how many deaths would have been prevented if the patients in question had received better treatment.
The management board let patients down as its primary concerns were cost cutting, achieving NHS Foundation Trust status and meeting financial targets. There was also a major failure by the Trust to adequately deal with serious concerns and complaints raised by patients and even staff.
Examples of poor care included patients being so thirsty that they had to drink water from dirty vases. Some nurses did not receive a minimum level of training and there were cases where doctors with insufficient experience were placed in charge of seriously ill patients. In some cases there was a failure to provide critically ill patients with pain relief leaving them in agony.
In addition the report highlighted a failure of communication by other agencies, including the local NHS Strategic Health Authority and Primary Care Trust, as well as the national healthcare regulator the Care Quality Commission, to bring the problems at Mid Staffordshire to the fore.
Robert Francis QC recommended that to prevent future instances like Mid Staffordshire it will require a commitment from all those working and connected to the NHS to ensure the wellbeing of the patient is at the centre of everything they do. This aim can be achieved by developing a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff, the breach of which should not be tolerated.
There should be a legally enforceable duty of candour on healthcare providers to give accurate information to patients where things have gone wrong. A similar recommendation was made by Sir Ian Kennedy following the Bristol Royal Infirmary Inquiry in 2001 but it was not implemented into law.
When there are serious failings senior managers should be capable of being legally accountable, as doctors and nurses already are. Many of the families affected by the failings at Mid Staffordshire are concerned that some of the former senior managers at the Trust who have subsequently left have not been properly held to account.
It was not recommended that the changes required significant reorganisation of the NHS, as major reforms are already underway through NHS and Social Care Act 2012 which will see Primary Care Trust and Strategic Health Authorities being abolished in April this year.
Speaking in Parliament following the publication of the report, the Prime Minister apologised to the families of those who suffered for the way the system allowed the failings to happen.
The Prime Minister announced that the Care Quality Commission will create a new Chief Inspector of Hospitals post to be responsible for a new inspections regime from autumn 2013.
It emerged yesterday that five other NHS Trusts, Colchester Hospital University NHS Foundation Trust, Tameside Hospital NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Basildon and Thurrock University Hospitals NHS Foundation Trust and East Lancashire Hospitals NHS Trust, are to have their mortality rates investigated by the Chief Medical Officer Professor Bruce Keogh. High death rates were one of the factors that triggered the original investigation at Stafford.
If you have concerns regarding medical care or if you have any queries in relation to the issues raised in this blog, please contact a member of our specialist medical negligence team who will be pleased to provide further advice and assistance.