Stafford Hospital deaths scandal- the background
Inexperienced doctors were put in charge of critically ill patients, receptionists left to decide who to treat in A&E and some patients were so thirsty they had to drink water from vases. Today, a public inquiry will publish its conclusions as to why serious problems at Stafford Hospital were not identified and acted upon sooner.
It is a landmark inquiry and the fifth major investigation into the scandal.
The first was prompted by complaints and statistics showing more people were dying at the hospital than would be anticipated. Data shows there were between 400 and 1,200 more deaths than would have been expected between 2005 and 2008.
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A report by the Healthcare Commission in March 2009 criticised the hospital for its "appalling" standards, and in February 2010 the findings of an independent inquiry chaired by Robert Francis QC detailed the "unimaginable" distress and suffering of patients between 2005 and 2008.
Examples include patients crying out for help after receiving pain relief late or not at all, and food and drink being left out of reach.
Both reports slammed the cost-cutting and target-centred atmosphere which had developed at Mid Staffordshire NHS Foundation Trust, which ran Stafford Hospital.
Announcing the public inquiry in June 2010, Health Secretary Andrew Lansley said the previous reports established “a culture of fear existed in which staff did not feel able to report concerns” and “a culture of secrecy existed in which the Trust Board shut themselves off from what was happening in their hospital and ignored their patients”.
The public inquiry, which will today publish its findings, was set up to examine why the grave problems at the Trust were not identified and acted upon sooner, and to recognise lessons to be learnt for the future of patient care.
The inquiry, which sat between November 2010 and December 2011, taking evidence from more than 160 witnesses over 139 days, has looked at the broader monitoring system in relation to Mid Staffordshire NHS Foundation Trust.
It has not considered individual cases of patient care, or looked specifically at the internal operation of the Mid Staffordshire Trust - that was the focus of the first inquiry.
The latest inquiry was set up after relatives of patients criticised the February 2010 inquiry for not considering whether the wider NHS system had been to blame.
Robert Francis QC was again asked to chair the inquiry, which has looked at the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire NHS Foundation Trust. This includes the role of senior management at the hospital, the local and regional NHS bodies responsible for it and the national organisations in charge of overseeing them.
It is hoped the inquiry will help explain how the scandal was allowed to happen by the wider system and why the alarm wasn't raised earlier. Why did the Primary Care Trust and Strategic Health Authority not see what was happening and intervene earlier? How was the Trust able to gain Foundation Status while clinical standards were so poor?
According to the Daily Telegraph, the official inquiry will today recommend NHS hospitals should face prosecution if doctors and nurses fail to blow the whistle on patients receiving poor care.
The Inquiry expenditure to date is £13,034,300.
Its report will be set out before Parliament later this morning, and Prime Minister David Cameron will deliver a statement to the House of Commons following Prime Minister's Questions.