Mid Staffordshire NHS Inquiry

On 17 March 2009 the Healthcare Commission published its report into the severe failings in emergency care provided by Mid Staffordshire NHS Foundation Trust between 2005 and 2008.

Robert Francis QC led an inquiry following these concerns. The inquiry report made many recommendations and all of them were accepted by the Department of Health and the Trust Board.


The report concluded that the trust did not have a grip on operational and organisational issues, with no effective system for the admission and management of patients admitted as emergencies. Nor did it have a system to monitor outcomes for patients, so it failed to identify high mortality rates among patients admitted as emergencies. This was a serious failing.

When the high rate was drawn to the attention of the trust, it mainly looked to problems with data as an explanation, rather than considering problems in the care provided. The trust’s board and senior leaders did not develop an open, learning culture, inform themselves sufficiently about the quality of care, or appear willing to challenge themselves in the light of adverse information.

The clinical management of many patients admitted as emergencies fell short of an acceptable standard in at least one aspect of basic care. Some patients, who might have been expected to make a full recovery from their condition at the time of admission, did not have their condition adequately diagnosed or treated.  The trust was poor at identifying and investigating such incidents.

In the trust’s drive to become a foundation trust, it appears to have lost sight of its real priorities. The trust was galvanised into radical action by the imperative to save money and did not properly consider the effect of reductions in staff on the quality of care. It took a decision to significantly reduce staff without adequately assessing the consequences. Its strategic focus was on financial and business matters at a time when the quality of care of its patients admitted as emergencies was well below acceptable standards.

Based on the above findings, the inquiry reported a number of lessons relevant to the whole NHS. These include the need for:

• Trusts to be able to get access to timely and reliable information on comparative mortality and other outcomes, and for trusts to conduct objective and robust reviews of mortality rates and individual cases, rather than assuming errors in data.

• Trusts to identify when the quality of care provided to patients admitted as emergencies falls below acceptable standards and to ensure that a focus on elective work and targets is not to the detriment of emergency admissions. Care must be provided to an acceptable standard 24 hours a day, seven days a week.

• Trusts to ensure that a preoccupation with finances and strategic objectives does not cause insufficient focus on the quality of patients’ care.

• Trusts to ensure that systems for governance that appear to be persuasive on paper actually work in practice, and information presented to boards on performance (including complaints and incidents) is not so summarised that it fails to convey the experience of patients or enable nonexecutives to scrutinise and challenge on issues relating to patients’ care.

• Senior clinical staff to be personally involved in the management of vulnerable patients and in the training of junior members of staff, who manage so much of the hour-by-hour care of patients.

• Trusts to identify and resolve shortcomings in the quality of nursing care relating to hygiene, provision of medication, nutrition and hydration, use of equipment, and compassion, empathy and communication.

• Good handovers when reorganisations and mergers occur in the NHS.

• PCTs to ensure that they have effective mechanisms to find out about the experience of patients and the quality of care in the services that they commission.


Comments are closed.