1. +
The report of the Mid Staffs
Public Inquiry
Dr Rosie Belcher
ST6 St Mary’s Hospital
16.3.13

2. +
Content
 Background: the situation at Mid Staffs
 Report of the Independent Inquiry (“Francis 1”)
 Report of the Public Inquiry (“Francis 2”)
 This is a look at the Francis report and it’s potential implications for
individual doctors and jobbing geriatricians. I’ve also looked in
particular at his recommendations for medical education and
training. It is not a comprehensive summary! I’ve skipped a lot of
stuff about standards as this is of less immediate relevance.
 I have indicated Recommendations from Francis like this.
Numbers in brackets refer to the number of the recommendation in
the report (in case you want to check up). There are 290
recommendations in total.

3. +
Mid Staffordshire Foundation Trust
 Concerns about lack of clinical governance, low staff levels and
poor standards at the Trust had existed for some time (at least
prior to 2004)
 Trying to become a Foundation Trust 2005-2008
 2007 Concerns raised about mortality rates (SHMR)
 Although there has been interesting debates about these since – see
http://www.bmj.com/content/346/bmj.f562, and the linked editorial, and
responses from others.
 April 2008 Healthcare Commission (HCC) launched investigation,
NOT as a result of the actual mortality stats, but due to concern
about:
 The Trust’s reaction to the mortality stats
 The Trust’s reaction to complaints

4. +
Healthcare Commission report
 Healthcare Commission (HCC) reported in March 2009 on failings in emergency care.
 Triggered
 Review of hospital’s procedures for emergency admissions and treatment
 Investigation of how commissioning and performance management systems missed what was
happening in the department
 But there were focused on A&E. There was growing pressure from the public, particularly a
local group (Cure the NHS, set up by a relative of someone who had died at Mid Staffs) to
look at other departments, and to do this through a Public Inquiry.
 July 2009 Andy Burnham conceded and set up an Independent Inquiry and Robert Francis
QC.
 Reported Feb 2010 on:
 Individual patient cases and internal operations of the Trust
 Identify further lessons to be learned
 Suggest additional action to be taken to ensure good care

5. +
Independent Inquiry (“Francis 1”)
 Lack of basic care across numerous wards and departments
 Culture at the Trust was not helpful
 Fear of adverse consequences for reporting problems
 Low morale
 High priority placed on achievement of (financial) targets and acceptance of poor
standards
 Consultant body was dissociated from management
 Management dominated by financial targets and achieving Foundation status
 No effective clinical governance, and a failure to recognize or attempt to correct
this
 Statistics and data were preferred to patient experience data, focus on systems
not outcomes
 Where problems were recognized, there was a lack of urgency in solving them.

6. +
Independent Inquiry (“Francis 1”):
recommendations
 The Trust should make visible it’s first priority to deliver a high standard of care and should
develop links with other organizations to help it do this
 The Trust, the Royal Colleges, the deanery and the school of nursing should review their
training programmes
 Improve audit and clinical governance processes
 Foster a culture of openness, including openness to staff members who raise concerns
about care
 Sec State for Health and Monitor should review the appointment and accountability of
directors of NHS Trusts, with a view to creating professional standards overseen by an
independent body
 Consider an “independent examination of the operation of commissioning, supervisory and
regulatory bodies in relation to their monitoring role at Stafford hospital with the objective of
learning lessons about how failing hospitals are identified”
 i.e. Francis was recommending a further, more wide-ranging inquiry in to why it took so
long for the bodies that were supposed to regulating the hospital to notice

7. +
Public Inquiry (“Francis 2”)
 So a Public Inquiry, under the Inquiries Act 2005 was set up to do this.
 Public Inquiries can
 Compel individuals to give evidence
 Command documentary evidence (eg can demand to see internal Trust
communication, minutes of meetings etc)
 They are held in public (obviously!). Francis held most hearings in
Stafford, to give locally affected people the opportunity to attend.
 Commissioned to examine:
 Commissioning, supervisory and regulatory organizations in relation to their
monitoring role at Mid Staffs
 Why serious problems at the Trust were not identified or acted on sooner
 Identify lessons to be drawn
 Make recommendations to the Secretary of State for Health
 Reported Feb 6th 2013

8. +
Public Inquiry: themes
 Certain themes keep recurring in the report
 Culture of the Trust
 Need for more information sharing/co-working between
organizations with different but overlapping
interests/responsibilities
 Constant structural change, with consequent loss of
expertise/information
 Makes lots of recommendations, on a wide range of topics.
 Following slides are a summary of some sections of the report,
with the relevant recommendations

9. +
Public Inquiry: Introduction 1
 Received numerous requests to examine failures of systems in other Trusts and services
 “Stafford was not an event of such rarity or improbability that it would be safe to assume that it has not
been and will not be repeated” (para 76)
 Francis does not go so far as to say that he thinks there are definitely other instances of care as poor
as at Mid Staffs, but implies this is likely to be the case
 Notes that the Health and Social Care Act 2012 was passed during the Inquiry
 Structural changes in the NHS
 Numerous bodies investigated to longer exist in their previous form (eg HCC  CQC)
 “This report should not be understood as intending to offer a comprehensive and up to the minute
account of the current position” (para 37)
 There is a sense of frustration in the report that the ground was shifting underneath him and in some
ways the report was already out of date by the time it was published
 Recommendation: “Before a proposal for any major structural change to the healthcare system is
accepted, an impact and risk assessment should be undertaken by the DH and should be debated
publicly.” (286)
 Recommendation: Future transitions should be managed in reasonable timescales, maintaining
corporate memory, and information and documentation (286)

10. +
Public Inquiry: Introduction 2
 Previous inquiries have resulted in a lack of accountability for
implementing changes
 Recommendation: All healthcare organizations should consider how
the findings and recommendations of the report should be applied to
them, and announce publically how they are going to respond (1)
 Recommendation: Healthcare organizations should then publish at
least annually information about their actions on the
recommendations (1)
 Recommendation: DH should collate this information (1)
 I cannot find any responses on local Trust websites, including
Imperial.

11. +
Public Inquiry: “Warning signs”
 Managers and regulators consistently said they had no idea about the problems
throughout both inquiries
 Francis dismisses this and gives a number of warning signs which should have been
heeded:
 Negative culture  Professional disengagement
 Tolerance of poor standards  Especially senior consultants
 Isolation from practice elsewhere
 Denial when concerns were raised
 Poor governance
 Clinical governance systems were
 Culture of self promotion rather
than critical analysis “vestigial”
 Patients not heard  Focus on finances not standards of
care
 Procedures for dealing with
complaints and SUIs were
inadequate  Inadequate risk assessment of staff
reduction
 Staff and patient surveys showed
dissatisfaction, but were ignored

12. +
Culture
 Francis comments repeatedly on the culture at the Trust, where
staff generally had low morale and were disengaged from
management processes. The culture tolerated poor standards and
discouraged staff from raising their concerns
 Francis suggests there needs to be more openness, transparency
and candour
 Recommendation: “Gagging” clauses should not be permitted (179)
 Recommendation: A statutory duty of candour by healthcare workers
towards individual patients when there has been an error (174, 181)
 Recommendation: A statutory duty of candour by healthcare
organisations towards regulatory and commissioning bodies (176, 182)
 Including a criminal offence for any registered healthcare
professional, manager or director to make an untruthful statement to
a regulator, or obstruct the performance of a regulator’s duties (183)

13. +
GPs
 Local GPs only expressed concerns after the HCC
investigation was announced
 Were they unaware, or aware and apathetic?
 Francis thinks GPs should monitor the care their patients get
from other local providers
 Recommendation: GPs “should have an obligation to their patients
to keep themselves informed of the standard of service available
from providers” and make any concerns known to the CQC and
relevant commissioner (123)
 Unclear if this is a collective or individual responsibility

14. +
Monitor
 Determines whether Trusts can become Foundation trusts and
ensures that Foundation Trusts comply with their conditions
 Is the Trust well governed?
 Is the Trust financially viable?
 Is the Trust legally constituted?
 Francis comments that there was a failure of the application
process as it did not identify the problems at Mid Staffs
 Monitor’s focus was on finance and corporate governance
 Monitor relied on the Trust’s assurances on clinical issues, and did
not probe
 Monitor did not talk to the HCC

15. +
Healthcare Commission
 Aim was to promote and drive improvement in quality of
healthcare
 Statutory duty to assess the provision and quality of healthcare
and review the performance of all NHS Trusts
 Report criticises standards for being formulated by the DH with
little clinician input or buy-in. Standards are also mixture of very
general and v specific.
 Reliance on self assessment and presence of systems, rather than
actual achievements and outcomes
 Statements by the Trust were accepted at face value without
challenge
 Thoroughness of the eventual investigation is praised however

16. +
Care Quality Commission
 Report comments that has clearly faced a number of
challenges but seems to have planned activities to fit the
resources available, rather than the job it is commissioned to
do.
 Report characterizes it as a defensive organization, which did
not respond to concerns about itself constructively
 Report makes a large number of recommendations about these
organizations (or their successors) and in particular about the
standards that they use.

17. +
Information
 There was a lack of information sharing between all
organizations.
 Recommendation: All healthcare providers should publish
information on the performance of their consultants and specialist
teams (262)
 Morbidity
 Mortality
 Outcomes
 Patient satisfaction
 Recommendation: Health and Social Care Information Centre for
collection analysis and publication of healthcare information (257)
 To include some of the functions of the National Patient Safety
Agency
 Recommendation: Electronic patient records, with the facility for
patients to read and comment on them (244)

18. +
GMC and NMC
 Three doctors are facing fitness to practice hearings
 All had significant managerial responsibilities as MD/deputy MD
 GMC and NMC are criticized for dealing with cases individually only
 Recommendation: Should have a policy covering generic complaints were
no individuals or multiple individuals are named (222)
 Recommendation: Should be more proactive in investigating based on
monitoring fitness to practice, not just complaints (222)
 Recommendation: Should liaise more closely with each other and the
CQC (234)
 Recommendation: Suggests there should be an independent tribunal to
deal with issues involving professionals from more than one field (235)

19. +
Medical Education and Training 1
 No concerns about the Trust were raised through those with
oversight of training of healthcare professionals
 Concerns about bullying/abuse of students and trainees were
not followed up
 Recommendation: Medical schools should actively seek feedback
from students about the quality of care on their placements (158)
 Recommendation: Medical students and trainees should be
surveyed about their perceptions of the standards of care in their
placements (159)
 This is started in 2012 in the new GMC survey for trainees. 5% of
trainees suggested they had concerns about care in their
workplace. See www.gmc-
uk.org/NTS_2012_response_to_concerns_summary.pdf_5023779
2.pdf

20. +
Medical education and training 2
 PMETB/GMC/Deaneries did not consider patient safety
standards as relevant to them
 There is little communication between patient safety/clinical
standards organizations and medical education organizations.
 Recommendation: Any organization which identifies a problem with
patient care which is potentially relevant to training should be
required to inform the training regulator (152)
 Recommendation: Statutory duty of co-operation and information
sharing between deanery (?LETB et al) CMG, CQC and Monitor
(153)

21. +
Medical education and training 3
 There is a general reluctance to impair the provision of services
through the removal of trainees
 Good care is critical for good training. Those with oversight of
training must be aware of the standards of care in
organizations in which they place their students/trainees
 Recommendation: Should be standard requirements for routine
visits to training providers. Visits should involved deanery, Royal
College and lay representation, and should be informed by other
sources of info eg CQC (155)
 Recommendation: Areas which do not comply with fundamental
patient safety and quality standards should not be allowed to take
trainees or students (162)

22. +
Caring for patients, particularly the
elderly
 The elderly seemed to be particularly effected by poor nursing
care
 Recommendation: All ward rounds should include the nurse
responsible for those patients (238)

23. +
Summary: for debate
 Highly critical in particular of the culture of the Trust
 Recommendations
 Statutory duty of candour
 GPs have duty to monitor standards of care at secondary care facilities.
 Is this practical? Is it reasonable?
 GMC should investigate when no individuals are named
 Something similar to the concept of corporate manslaughter. But how
practical is it for the GMC to do this? Such investigations could be
extremely large.
 Publication of performance data for all clinical teams/consultants
 Controversial, there is some evidence that it improves quality of care.
But in the UK so far has only been done for surgeons, within specific
fields. How practical is this for other specialties?

24. +
For more info…
 A cluster of BMJ articles
 www.bmj.com/about-bmj/article-clusters/mid-staffs
 The public inquiry website.
 The executive summary of the report contains a reasonable level of
detail and is very readable.
 www.midstaffspublicinquiry.com
 The independent inquiry website
 www.midstaffsinquiry.com
 Review article re performance data and quality of care
 http://annals.org/article.aspx?articleid=738899