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Mid Staffs report calls for sweeping changes to improve patient safety Mid Staffs report calls for sweeping changes to improve patient safety
(35 minutes later)
Hospital staff and managers should face prosecution if patients are harmed or killed as a result of poor care as part of sweeping changes to finally end the NHS's neglect of patient safety, the landmark report into the Mid Staffordshire scandal has recommended.Hospital staff and managers should face prosecution if patients are harmed or killed as a result of poor care as part of sweeping changes to finally end the NHS's neglect of patient safety, the landmark report into the Mid Staffordshire scandal has recommended.
The report by Robert Francis QC, who chaired the 31-month public inquiry into the scandal, amounted to a damning indictment of NHS attitudes, practices and organisations.The report by Robert Francis QC, who chaired the 31-month public inquiry into the scandal, amounted to a damning indictment of NHS attitudes, practices and organisations.
Francis made no fewer than 290 recommendations, which he said were designed to ensure that patients' interests became the top priority for the NHS and that in future any lapses in care standards are detected and stopped right away, unlike at Stafford hospital.Francis made no fewer than 290 recommendations, which he said were designed to ensure that patients' interests became the top priority for the NHS and that in future any lapses in care standards are detected and stopped right away, unlike at Stafford hospital.
David Cameron will deliver the government's response later on Wednesday. Ministers will now have to contemplate further changes to the NHS's system of regulation – which Francis has found to be seriously wanting – and monitoring of hospitals. David Cameron will deliver the government's response later on Wednesday. Ministers will have to contemplate further changes to the NHS's system of regulation – which Francis has found to be seriously wanting – and monitoring of hospitals.
An estimated 400-1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at Stafford in one of the biggest NHS scandals.An estimated 400-1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at Stafford in one of the biggest NHS scandals.
While the hospital trust itself bore most of the responsibility for allowing "appalling suffering of many patients" to go unchecked between 2005 and 2009, multiple failures by a wide array of organisations and individuals across "the NHS system" allowed poor care to persist and meant opportunities to intervene were not taken, Francis said.While the hospital trust itself bore most of the responsibility for allowing "appalling suffering of many patients" to go unchecked between 2005 and 2009, multiple failures by a wide array of organisations and individuals across "the NHS system" allowed poor care to persist and meant opportunities to intervene were not taken, Francis said.
Patients were left at risk at the hospital even after the then NHS regulator sounded the alarm about unusually high death rates there, he added. Checks and balances designed to protect patients did not prevent "serious systemic failure of this sort", Patients were left at risk at the hospital even after the then NHS regulator sounded the alarm about unusually high death rates there, he added. Checks and balances designed to protect patients did not prevent "serious systemic failure of this sort".
In a scathing assessment of the trust's board of directors he accused it of "a serious failure" of its duties: "It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the trust's attention. [It also] failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from management and leadership responsibilities." In a scathing assessment of the trust's board of directors, Francis accused it of "a serious failure" of its duties. "It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the trust's attention. [It also] failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from management and leadership responsibilities," he said.
But he also cited the hospital A&E unit's need to treat 98% of patients arriving there within four hours to meet the government's key NHS targets, the trust's attempts to balance its books and its "seeking foundation trust status … at the cost of delivering acceptable standards of care" as contributory factors.But he also cited the hospital A&E unit's need to treat 98% of patients arriving there within four hours to meet the government's key NHS targets, the trust's attempts to balance its books and its "seeking foundation trust status … at the cost of delivering acceptable standards of care" as contributory factors.
Francis said that in future the NHS should have a relentless focus on fundamental standards of care which, if breached, should lead to serious sanctions. Francis said in future the NHS should have a relentless focus on fundamental standards of care which, if breached should lead to serious sanctions.
"Any service or part of a service that does not consistently fulfil the relevant fundamental standards should not be permitted to continue," Francis said, in a move which could see hospital units where concerns arise shut down. "Any service or part of a service that does not consistently fulfil the relevant fundamental standards should not be permitted to continue," Francis said, in a move that could lead to the closure of hospital units arousing concern.
In addition, "non-compliance with a fundamental standard leading to death or serious harm of a patient should be capable of being prosecuted as a criminal offence, unless the provider or individual concerned can show that it as not reasonably practical to avoid this", he recommended.In addition, "non-compliance with a fundamental standard leading to death or serious harm of a patient should be capable of being prosecuted as a criminal offence, unless the provider or individual concerned can show that it as not reasonably practical to avoid this", he recommended.
He also recommended the creation of in effect one new super-regulator for the NHS to scrutinise both clinical and financial standards. Those tasks are currently performed separately by two watchdogs, the Care Quality Commission (CQC), which regulates care, and Monitor, which regulates semi-independent foundation trust hospitals and is due to become the NHS in England's overall financial regulator in April. Francis also recommended the creation of, in effect, one new super-regulator for the NHS to scrutinise both clinical and financial standards. Those tasks are currently performed separately by two watchdogs – the Care Quality Commission (CQC), which regulates care, and Monitor, which regulates semi-independent foundation trust hospitals and is due to become the NHS in England's overall financial regulator in April.
In a letter to the health secretary, Jeremy Hunt, accompanying his report, Francis said the causes of the NHS's failings at Mid Staffs included:
• A culture focused on doing the system's business – not that of patients
• Too great a degree of tolerance of poor standards and of risk to patients
• An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern
• A failure of communication between the many agencies to share their knowledge of concerns.