Francis report - public inquiry

Robert Francis QC, Chairman of the Inquiry has now published his final report following consideration of over 250 witnesses and over one million pages of documentary evidence.

The Inquiry has been examining the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire hospital between January 2005 and March 2009.

Robert Francis QC

It has been considering why the serious problems at the trust were not identified and acted on sooner, and identifying important lessons to be learnt for the future of patient care.

It builds on Mr Francis’s earlier report, published in 2010 after the earlier independent inquiry on the failings in the Mid Staffordshire NHS Foundation Trust between 2005 and 2009. The Inquiry identifies a story of terrible and unnecessary suffering of hundreds of people who were failed by a system which ignored the warning signs of poor care and put corporate self interest and cost control ahead of patients and their safety.

The chairman has made 290 recommendations designed to change this culture and make sure patients come first by creating a common patient centred culture across the NHS and as a trust we are looking at these, which include:

A structure of fundamental standards and measures of compliance:

  • A list of clear fundamental standards, which any patient is entitled to expect which identify the basic standards of care which should be in place to permit any hospital service to continue.
  • These standards should be defined in genuine partnership with patients, the public and healthcare professionals and enshrined as duties, which healthcare providers must comply with.
  • Non compliance should not be tolerated and any organisation not able to consistently comply should be prevented from continuing a service which exposes a patient to risk.
  •  To cause death or serious harm to a patient by non compliance without reasonable excuse of the fundamental standards, should be a criminal offence.
  •  Standard procedures and guidance to enable organisation and individuals to comply with these fundamental standards should be produced by the National Institute for Clinical Excellence with the help of professional and patient organisations.
  • These fundamental standards should be policed by the Care Quality Commission (CQC)

Openness, transparency and candour throughout the system underpinned by statute. Without this a common culture of being open and honest with patients and regulators will not spread. Including:

  • A statutory duty to be truthful to patients where harm has or may have been caused
  • Staff to be obliged by statute to make their employers aware of incidents in which harm has been or may have been caused to a patient
  • Trusts have to be open and honest in their quality accounts describing their faults as well as their successes
  • The deliberate obstruction of the performance of these duties and the deliberate deception of patients and the public should be a criminal offence
  • It should be a criminal offence for the directors of trusts to give deliberately misleading information to the public and the regulators
  • The CQC should be responsible for policing these obligations

Improved support for compassionate, caring and committed nursing

  • Entrants to the nursing profession should be assessed for their aptitude to deliver and lead proper care, and their ability to commit themselves to the welfare of patients
  • Training standards need to be created to ensure that qualified nurses are competent to deliver compassionate care to a consistent standard
  • Nurses need a stronger voice, including representation in organisational leadership and the encouragement of nursing leadership at ward level
  • Healthcare workers should be regulated by a registration scheme, preventing those who should not be entrusted with the care of patients from being employed to do so

Stronger healthcare leadership

  • The establishment of an NHS leadership college, offering all potential and current leaders the chance to share in a common form of training to exemplify and implement a common culture, code of ethics and conduct
  • It should be possible to disqualify those guilty of serious breaches of the code of conduct or otherwise found unfit from eligibility for leadership posts
  • A registration scheme and a requirement need to be established that only fit and proper persons are eligible to be directors of NHS organisations.

Professor Tricia HartSouth Tees chief executive, Professor Tricia Hart, was one of a small team of assessors appointed to work alongside him and has, over three years, attended hearings, parts of hearings, prepared reports and provided advice on matters relevant to the Inquiry.

The trust fully accepts the recommendations and is now going through them in detail. Tricia will be asking  the newly appointed director of nursing and quality assurance, plus the medical director and our deputy director of governance and quality to lead this crucial work.

She has also been asked by the Prime Minister David Cameron to undertake a review of complaints procedures in NHS hospitals alongside Labour MP Ann Clwyd and welcome the opportunity to look into this system.

“Our organisation has a 20-year culture of focussing on openness and service improvement and looking at how patient safety and the overall patient experience can be continually improved upon,” she said.

“However we are not complacent. We know we have more to do at every level of the organisation. From the Board to wards, departments and community teams, we need to reflect on the findings of the report and how we are going to achieve our vision of being not only the safest trust across the North east but the safest in the country.”