Mid-Staffordshire report (Francis report) 2013

The Mid Staffordshire NHS Foundation Trust Public Inquiry was announced on 9 June 2010 by the Secretary of State for Health (Andrew Lansley MP).

The Inquiry was established to examine the commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. The Inquiry was chaired by Robert Francis QC and considered why the serious problems at the Trust were not identified and acted on sooner and draw lessons to be learnt for the future of patient care.

The final report of the Inquiry was published on Wednesday 6 February 2013.

The final report of the public inquiry into Mid Staffordshire NHS Foundation Trust provides detailed and systematic analysis of what contributed to the failings in care at the trust. It recognises that what happened in Mid Staffs was a system failure, as well as a failure of the organisation itself. Rather than proposing a significant reorganisation of the system, the report concludes that a fundamental change in culture is required to prevent this system failure from happening again, and that many of the changes can be implemented within the current system. It stresses the importance of avoiding a blame culture, and proposes that the NHS – collectively and individually –adopt a learning culture aligned first and foremost with the needs and care of patients.

The report identifies that the failures of the Trust 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 report says ‘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 a 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.

 

The Francis report makes 290 recommendations along the following themes:

1. Foster a common culture shared by all in the service of putting the pt first;

2. Develop fundamental standards and measures of compliance:

  • Develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff
  • 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 that the relentless focus of the healthcare regulator is on policing compliance with these standards. Non-compliance with these standards 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.
  • These fundamental standards should be policed by the Care quality commission (CQC)
  • The merger of the regulation of care into one body – with Monitor responsibilities being absorbed by the CQC over time

3. Ensure 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:

  • The “ duty of candour” – 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

4. 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;

a. 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.

b. 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.

So in summary, Francis report recommends making 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. It also recommends development and sharing of 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.

Ref:

http://www.midstaffspublicinquiry.com/report

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