Stafford Hospital deaths caused by 'insidious negative culture', says Francis report
UP TO 1,200 patients died needlessly at Stafford Hospital because of its ‘insidious negative culture’, an inquiry has found.
Robert Francis QC’s long-awaited report on the biggest scandal in the history of the NHS says it was primarily caused by the serious failures of the Mid Staffordshire hospitals trust board
The trust reacted too defensively to complaints, tolerated poor standards and was overly focused on meeting targets in order to achieve foundation status, at the expense of patient care.
But Mr Francis has also identified failures throughout the NHS system, from local scrutiny bodies to the Department of Health.
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He said the ‘plethora’ of external agencies left ‘regulatory gaps’, resulting in the different bodies assuming someone else would follow up warning signs.
But Mr Francis said a ‘fundamental culture change’, rather than a root and branch reorganisation, was needed to prevent such failures reoccurring.
Key recommendations include:
- placing a statutory ‘duty of candour’ on NHS doctors and nurses, with staff facing criminal prosecution if they block or mislead investigations;
- making the Care Quality Commission the single regulator for fundamental standards within the NHS, taking over responsibilities from foundation trust watchdog Monitor;
- requiring local authorities to pass over funding to Local Healthwatch organisations;
- an increased focus on a culture of compassion and caring in nurse recruitment, training and education;
- the creation of a common code of ethics for managers and board members;
- greater involvement of patients and public in all that is done.
Mr Francis hoped the report, his second on the Stafford Hospital scandal, would contribute to making the patient the primary consideration of everyone within the NHS.
He said: “Building on the report of the first inquiry, the story it tells is first and foremost of appalling suffering of many patients. This was primarily caused by a serious failure on the part of the 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.
“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.”
Ministers called for the public inquiry after previous investigations uncovered evidence of 'appalling' standards of care at the hospital.
The inquiry sat for 139 days, heard from 164 witnesses and received more than 1 million pages of evidence.