On 6 February 2013, Robert Francis QC published his long awaited findings from his public inquiry into patient care provided by Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009.
In 2007 the Healthcare Commission (the hospital regulator at the time) identified that the trust had an unusually high death rate and various reports and investigations were subsequently commissioned. The initial reports highlighted sufficient areas of concern about patient care, staff shortages and culture that a public inquiry was instigated in July 2010. It was significant that a public inquiry was commissioned as the last health-related public inquiry was the 2005 Shipman Inquiry.
The inquiry was asked to come up with recommendations to help prevent the identified failings in the future. Robert Francis was involved from the outset and, since the commencement of the public inquiry, has been working on his report.
As widely expected, the report is extremely critical of the commissioning, management and regulation of the NHS, identifying systemic failings at multiple levels. The report identifies a number of core problems including a culture focused on business and staff rather than on patients; a tolerance of poor standards of patient care; a failure to accept and respond to legitimate complaints; a lack of accountability and a system that encourages a lack of openness, defensiveness and complacency; a failure of leadership; and a ’somebody else’s problem’ attitude amongst staff.
Mr Francis made nearly 300 recommendations for improvements to patient care at the Mid Staffordshire Trust and also made it clear that a number of his findings and recommendations applied to trusts throughout the NHS. A significant number of the recommendations involved radical changes focused on improving patient safety and a key theme of his report was the need for a culture change. These recommendations include proposals to make serious but avoidable medical mistakes causing harm or death to a patient a criminal offence; a legal ‘duty of candour’ on NHS staff; and clear lines of leadership at all levels.
The final report of the public inquiry has now been published and the Government has said it will respond to its recommendations in March 2013. Changes required by earlier reports into the Mid Staffordshire failings are already under way.
Philippa Luscombe, partner in the clinical negligence team at Penningtons Solicitors LLP, said: “The extent to which standards of patient care were allowed to deteriorate at the Mid Staffordshire Trust is both alarming and saddening. The report makes hard reading in terms of learning about its culture and standards. We have encountered patients and their families treated by the trust and have been dismayed to see how they have suffered from these standards which are clearly well below what would be expected.
“That said, it is positive that the problems were identified and that the Government has taken steps to investigate by initiating the public inquiry. It is clear that a very thorough investigation has been done and there are some good and tangible recommendations. We hope that the recommendations made by Mr Francis and his team are taken seriously and that a real change takes place to restore patient safety to its rightful place as the number one priority.”