Stafford Hospital deaths scandal: Patients were let down by 'catastrophic failings'
AN 'ENGRAINED culture' which tolerating poor standards allowed up to 1,200 patients to die needlessly at Stafford Hospital.
Robert Francis QC, who has published his long-awaited report into the scandal, said board members and other leaders at the hospital trust failed to appreciate the 'enormity' of what was happening at Stafford between 2005 and 2009.
Horror stories included patients left overnight in wet or soiled beds, thirsty patients drinking water from vases, and patients going without food.
Mr Francis said an obsession with achieving targets and cutting costs resulted in countless warning signs going unheeded.
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A 'plethora' of external agencies – from primary care trusts (PCTs), to strategic health authorities and the Department of Health itself – had also failed to react correctly.
'Regulatory gaps' and a lack of communication between organisations meant different bodies always assumed it was someone else's responsibility to deal with the problems at Stafford.
But Mr Francis said those with the most clear and close responsibility for ensuring good care were the leaders of the Mid-Staffordshire Trust.
The Trust did not listen to patients' concerns, failed to adequately assess the risks of reducing staff levels, and adopted a culture of 'self promotion rather than critical analysis'.
Mr Francis said: "Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities.
"This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care."
The constant reorganisation of the primary care trust system throughout the period made it more difficult for South Staffordshire PCT – which covers Stone and Eccleshall – to monitor the delivery of the services it commissioned.
Mr Francis added: "While the PCT cannot be criticised for the fact of reorganisation itself, it failed to put in place systems and processes to manage the inevitable risks that would occur as the new system established itself."
West Midlands Strategic Health Authority (SHA), which took over from Shropshire and Staffordshire SHA, did respond to concerns once it became aware of them.
But Mr Francis said it placed too much trust in provider boards, and failed to seek out or address patient safety.
Mr Francis made 290 recommendations for reforms throughout the NHS, and called for a 'fundamental culture change' in the organisation.
Key recommendations included:
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;
An increased focus on a culture of compassion and caring in nurse recruitment, training and education.
Just days before the publication of the Francis Report, the Mid-Staffordshire Trust was forced to apologise once again after a baby boy was found with a dummy taped to his face at Stafford Hospital.
But trust chief executive Lyn Hill-Tout insisted that the quality of care at Stafford had improved significantly. She said: "Stafford Hospital is in a very different place to where it was. There are more nurses on the wards and we've changed the ratio of qualified nurses to unqualified nurses and are making sure there's a ward sister on every ward who can provide support and supervision."
Mrs Hill-Tout apologised unreservedly and accepted that the board and individuals working for the trust had failed to keep patients safe.
A spokesman for South Staffordshire PCT also offered apologies, and thanked families who had campaigned to highlight the problems. He said: "The PCT apologises for not identifying such poor levels of care, before it was brought to our attention in 2008, and regrets, it was not sufficiently proactive enough in identifying the quality and standard of care that has been provided, as well as the unnecessary anguish suffered by so many patients and their families. Much has been learnt since 2009."
A spokesman for NHS Midlands and East SHA cluster said the scandal at Stafford Hospital represented a series of 'catastrophic failings' by various NHS bodies.
The spokesman said: "The terrible care that patients received at the Mid Staffordshire NHS Foundation Trust was not the fault of one person, organisation or profession. "Regulators and supervisory bodies, such as the SHA, did not identify what was happening soon enough and so did not intervene quickly enough.
"But it should be remembered that the care that was provided was the prime responsibility of the Mid-Staffordshire Trust."