The report into the Mid Staffordshire care scandal says hundreds of patients were exposed to risk because of systemic failings “at every level”, but stops short of laying blame at individuals.
The landmark report into the how the failure of care at Mid Stafforshire was allowed to go on for so long proposes wide-ranging reforms of the NHS, including a “zero tolerance” approach to poor standards of care.
Robert Francis QC said hospitals which failed to comply with a “fundamental standard” should be forced to close, and put the onus on staff to speak out: he recommends that any NHS member who fails to be open and transparent with patients or relatives, or who stops another member of staff from speaking out, should be prosecuted.
In a move that will be welcomed by patients groups, Mr Francis also called for a gagging clauses to be removed from contracts, allowing whistleblowers to speak out, as well as a statutory “duty of candour”, so that if an NHS worker believes a patient has been harmed or killed, they are legally obliged to tell someone.
The inquiry chairman made a total of 290 sweeping recommendations for healthcare regulators, providers and the government in his 1,782 page report, which attacks local health authorities and the trust board, but does not blame any one individual or organisation for the “disaster” at Stafford Hospital.
Mr Francis said the NHS has a series of checks and balances which should have prevented “serious systematic failure of this sort”.
The prime minister told parliament that he had asked NHS Medical Director Professor Bruce Keogh to conduct an immediate investigation into the care at hospitals with the highest mortality rates, to check that urgent remedial action is being taken.
The NHS commissioning board later announced that it would be looking into high mortality rates at the Colchester Hospital University NHS Foundation Trust, Tameside Hospital NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Basildon and Thurrock University Hospitals NHS Foundation Trust and East Lancashire Hospitals NHS Trust.
Speaking as the report was published, Mr Francis said: “This is a story of appalling and unnecessary suffering of hundreds of people.
Patients were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety. Robert Francis QC
“They were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.”
The system failed in its primary duty of protecting patients, he added, and there were “numerous” warning signs which should have alerted authorities to problems at the trust.
There was a failure to communicate between the plethora of regulatory agencies and “too great a degree of tolerance of poor standards”, he said, and proposed that fundamental standards should be policed by a single regulator – the Care Quality Commission (CQC), he said.
He added that the regulator Monitor should be stripped of its powers to award trusts foundation trust status – a supposed marker of excellence in the NHS. The regulator awarded the trust the status in 2008 – at the height of its troubles.
The public inquiry was ordered after it was revealed that between 400 and 1,200 people more people died than expected at Stafford Hospital between 2005 and 2009 amid “appalling” standards of care.
Patients were left for hours sitting in their own faeces, food and drink was left out of reach and hygiene was so poor that relatives had to clean toilets themselves. In addition to basic care errors there was a string of clinical blunders including botched operations, misdiagnoses and drugs were not given or given late.
Julie Bailey of campaign group Cure the NHS, lost her mother Bella, 86, whilst she was a patient at Stafford General Hospital and set up the campaign group, Cure the NHS. Today the David Cameron praised her efforts to publicise what was happening at the hospital as he spoke in the House of Commons:
“the anger of the families is completely understandable. Every honourable member in this house would be angry, would be furious, if their mother or their father or their loved ones were treated in this way, and rightly so.”
Mr Francis’s first report, drawn from the independent inquiry he chaired between 2009 and 2010, concluded that patients were “routinely neglected” while the trust was preoccupied with cost-cutting and targets.
The inquiry, which sat for 139 days, heard from heard from victims, their family members, patients’ groups, charities, medics, politicians, unions and representatives of some of the royal colleges.
Concerns have been raised that other organisations may suffer the same fate amid the NHS £20b efficiency drive.
And cases of poor care standards at the trust are still surfacing. Last week the trust confirmed that an employee at Stafford Hospital was suspended after taking photographs of patients. The week before it emerged that police were investigating after a baby was found with a dummy taped into its mouth.
Every day abuse against patients takes place, and it is usually the most vulnerable who suffer and without widespread reform it will continue. Human rights lawyer Emma Jones
Human rights lawyer Emma Jones said her firm Leigh Day is investigating claims of abuse at 10 other hospitals.
Ms Jones, who represented 120 victims of abuse at the trust, said: “Every day abuse against patients takes place, and it is usually the most vulnerable who suffer and without widespread reform it will continue.
“People who are admitted to hospital are vulnerable. They are often frightened and have not been told what is wrong with them, or what treatment they will receive.
“These issues need to be addressed and reforms put into place as a matter of urgency to ensure such a situation does not arise again.”
The Patients Association said that the government must urgently address the “care deficit” in the NHS.
“Whilst our first thoughts must be for those families and friends who lost loved ones so tragically in Mid Staffs, every possible action must be taken to avoid such an appalling scandal ever happening again,” said Chief Executive Katherine Murphy.