Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - The Francis Inquiry with 290 recommendations

Monday 25th March 2013

Akira NAITO MD PhD CT2 to Dr Duncan ANDERSON

Critical appraisal of this paper

This paper was produced within the Inquiry Act 2005 procedure although conducted by Barrister R Francis only with nominated assessors (not by a panel of authors). The latest version of the paper is the second inquiry into the same case. It was done in two fold because of the regulation the Inquiry Act 2005 was in place, i.e. restriction of time duration and of financial limit for one public inquiry. This increased these trustworthiness. The validity and reliability of the paper appear sound. The generalisability of this paper to other English NHS settings also appears medium to high given the provided evidence. The recommendations from this inquiry has already impacted upon all the English NHS healthcare professionals/staff and managers as well as all the public in England.

First report and the current report

Final report published in 2013 - Executive summary + Volume 1, 2 & 3 http://www.midstaffspublicinquiry.com/report

First report published in 2010 - Volume 1 and 2 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publication sPolicyAndGuidance/DH_113018

Background

The Healthcare Commission (the hospital regulator at the time) first raised concerns about the trust in 2007, after determining it had unusually high death rates. These concerns led to a series of reports, undertaken by different bodies, which all found widespread evidence of significant failures in care.

Examples of widespread evidence of significant failures in care:

Patients being left in soiled bedding Patients not given ready access to food and water Chronic staff shortages Failure in the leadership of the hospital A culture in which staff members who had concerns about failures in care were discouraged from speaking out

The result from the first inquiry (1)

(published on the 24.Feb.10) Lack of basic care across a number of wards and departments; The culture was not conducive to providing (1) good care for patients or providing (2) a supportive working environment for staff;

An atmosphere of fear of adverse repercussions; A high priority was placed on the achievement of targets; The consultant body largely dissociated itself from management; Low morale amongst staff; Lack of openness and an acceptance of poor standards;

The result from the first inquiry (2)

(published on the 24.Feb.10) Management thinking was dominated by financial pressures and achieving Foundation Trust status, to the detriment of quality of care; Management failure to remedy the deficiencies in staff and governance that had existed for a long time, including an absence of effective clinical governance; Lack of urgency in the Boards approach to some problems; Statistics and reports were preferred to patient experience data, with a focus on systems, not outcomes; Lack of internal and external transparency regarding the problems

Questions from the first inquiry (1)

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? Why did the regulatory bodies not act sooner to investigate a trust whose mortality rates had been significantly higher than the average since 2003 and whose record in dealing with serious complaints was so poor? The public deserve answers.

Questions from the first inquiry (2)

The previous reports are clear that the following existed:

a culture of fear in which staff did not feel able to report concerns; a culture of secrecy in which the trust board shut itself off from what was happening in its hospital and ignored its patients; and a culture of bullying, which prevented people from doing their jobs properly.

Yet how these conditions developed has not been satisfactorily addressed.

One of the key recommendations arising from the first inquiry report
A need for an independent examination of the operation of each commissioning, supervising and regulatory body: What the commissioners, supervisory & regulatory bodies did or did not do at Stafford; The methods of monitoring used, including the efficacy of the benchmarks used, the auditing of the information relied on, and a greater emphasis on actual inspection rather than self-reporting; Whether recent changes (including the Memorandum of
Understanding between Monitor and the Care Quality Commission (CQC), Quality Accounts and the registration of trusts by CQC) will

improve the process; What improvements are required to local scrutiny and public engagement arrangements; and the resourcing and support of foundation trust governors.

The Terms of Reference set for the 2nd inquiry based on the 1st report

To examine the operation of the commissioning, supervisory and regulatory organisations and other agencies, including the culture and systems of those organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009; and

The Terms of Reference (contd)

To examine why problems at the Trust were not identified sooner, and appropriate action taken. This includes, but is not limited to, examining, the actions of the Department of Health, the local strategic health authority, the local primary care trusts, the Independent Regulator of NHS Foundation Trusts (Monitor), the Care Quality Commission, the Health and Safety Executive, local scrutiny and public engagement bodies and the local Coroner.

Scope of the 2nd Inquiry

To make recommendations to the Secretary of State for Health based on the lessons learned from the events at Mid Staffordshire; and To use best endeavours to issue a report to him by March 2011

Executive summary (2nd) contents

Letter to the Secretary of State Introduction

Page 3
7 10 11 19 34

Background Scope of the Inquiry The first inquiry Constitution of the Inquiry Responsibility and criticism

Summary of findings
Warning signs 41 Analysis of evidence 43 Lessons learned and related key recommendations 65 Table of recommendations 85 Outline table of contents 117

Volume 1 (2nd): Analysis of evidence and lessons learned (part 1)

Letter to the Secretary of State Introduction Warning signs The Trust Complaints: process and support The foundation trust authorisation process Mortality statistics Patient and public local involvement & scrutiny Commissioning and the primary care trusts

Volume 2 (2nd): Analysis of evidence and lessons learned (part 2)

8.

9.
10. 11. 12.

13.
14. 15. 16. 17. 18. 19.

Performance management & strategic health authorities Regulation: the Healthcare Commission Regulation: Monitor Regulation: the Care Quality Commission Professional regulation Regulation: the Health and Safety Executive Certification and inquests relating to hospital deaths Risk management The Health Protection Agency The National Patient Safety Agency Medical training The Department of Health

Volume 3 (2nd): Present and future

20. 21. 22. 23. 24. 25. 26. 27.

Culture Values and standards Openness, transparency and candour Nursing Leadership in healthcare Common culture applied: the care of the elderly Information Table of recommendations

The findings of the (2nd) inquiry can fairly be described as damning.

A perfect storm of systematic failures of care, including:

A Somebody Else's Problem attitude among hospital staff An institutional culture that cared more about the needs of the hospital staff than the patients An unacceptable willingness to tolerate poor standards of patient care A failure to accept and respond to legitimate complaints A failure of different teams within the hospital, as well as in the wider community, to communicate and share their concerns A failure of leadership in particular, financial changes needed to achieve Foundation Trust status were seen, by the inquiry, to take precedence over patient care

Concise summary video by ITV

http://on.aol.com/video/mid-staffs-report--nhs-scandal-right-to-the-top-517664818

A patient death Systematic failure of safety?

Failure to:

Control diabetes Administer prescribed drugs Undertake nursing handovers properly or at all Complete nursing records adequately or at al Make adequate or proper notes of ward rounds and care plans Give patient a diabetic menus Report this matter as a SUI in a timely fashion Report to report to the Coroner

Lessons learned and related key recommendations

A common culture made real throughout the system: The negative aspects of culture in the system were identified as including: A lack of openness to criticism; A lack of consideration for patients; Defensiveness; Looking inwards not outwards; Secrecy; Misplaced assumptions about the judgments and actions of others; An acceptance of poor standards; A failure to put the patient first in everything that is done.

The systems business not the patients

GPs

Did not look for concerns Inward looking Insufficient support or expertise Did not listen

Patient and public groups

Scrutiny committees

PCTs

Not equipped to fulfill theoretical duty re inquiry

Did not react to potential safety implications

SHAs

DH

Insufficient attention to safety implications of reorganisation and targets Insuficient information to minister on concerns about the Trust

Regulators missing what was important for patients

CQC

Unhealthy culture
Standards system which missed the point Proved that rigorous expert inspection works Focus on finance and corporate governance No check on quality of delivery Left clinical care to others Limited view of patient safety Lack of proactivity

Healthcare Commission (HCC)

Monitor

HSE

GMC/PMETB

Professional and other groups not thinking enough of patients

RCN

Conflict between roles Ineffective support Information raising concerns not shared
Failed to uncover the lack of professionalism Failed to uncover the lack of professionalism and to take action to protect patients

RCS

University

Deanary

To change that:

There needs to be a relentless focus on the patients interests and the obligation to keep patients safe and protected from substandard care. This means that the patient must be first in everything that is done:

There must be no tolerance of substandard care; Frontline staff must be empowered with responsibility and freedom to act in this way under strong and stable leadership in stable organisations

First recommendation from the 2nd Inquiry

While the theme of the recommendations will be a need for a greater cohesion and unity of culture throughout the healthcare system, this will not be brought about by yet further top down pronouncements but by engagement of every single person serving patients in contributing to a safer, committed and compassionate and caring service. Therefore, the first recommendation of the report relates to the potential oversight of and accountability for implementation of its recommendations:

Re-emphasis of what is truly important:

Emphasis on and commitment to common values throughout the system by all within it; Readily accessible fundamental standards and means of compliance; No tolerance of non compliance and the rigorous policing of fundamental standards; Openness, transparency and candour in all the systems business; Strong leadership in nursing and other professional values; Strong support for leadership roles; A level playing field for accountability; Information accessible and useable by all allowing effective comparison of performance by individuals, services and organisation.

Value Clarity & Commitment

Put patients first

Staff put patients before themselves Staff do everything in their power to protect patients from avoidable harm Openness and honesty with patients regardless of consequences for themselves Direct patients to where assistanve can be provided Apply NHS values in all their work

Make NHS Constitution the shared reference point for value All NHS and contractors to commit to NHS values

NHS Constitution
http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Pages/Overview.aspx

Other key recommendations (1)

Causing harm or death to a patient due to avoidable failures in care should be a dealt with as a criminal offence (rather than a regulatory or civil matter) NHS staff, including doctors and nurses, should have a legal duty of candour so they are obliged to be honest, open and truthful in all their dealings with patients and the public A single regulator of both quality of care and financial matters should be created

Other key recommendations (2)

Non-disclosure agreements (gagging orders) where NHS staff agree not to discuss certain matters should be banned There should be a fit and proper test for hospital directors, similar to those set for football club directors A clear line of leadership needs to be established, so it is always clear who is ultimately in charge when it comes to a particular patient Uniforms and titles of healthcare support workers should be clearly distinguished from those of registered nurses

Proposals to improve assurance of Management and Quality (1)

An offence of causing death or serious injury to a patient through the breach of regulatory requirements A statutory duty of candour on all healthcare providers A criminal offence for any registered healthcare professional or director of an organisation to fail to provide honest information or obstruct that process A common code of ethics, standards and conduct for all NHS managers to form part of contractual obligations Support for a fit and proper persons test, which should include examination of a director's fitness to be in post and a requirement to comply with a common code of conduct

Proposals to improve assurance of Management and Quality (2)

Organisations must notify the regulator of all cases of non-compliance that result in dismissal or termination of appointment Disqualification of anyone found to be in serious noncompliance with the code from holding senior post Creation of a leadership college to provide standardised training to potential managers, which could form the basis of an accreditation scheme Strengthening oversight of governance in nonfoundation trusts to similar standards as those for foundation trusts.

List of responses from various organisations to the Inquity on the NeLM website
http://www.nelm.nhs.uk/en/NeLM-Area/News/2013---February/06/Francis-reportReport-of-the-Mid-Staffordshire-NHS-Foundation-Trust-Public-Inquiry/

Website of Francis enquiry Prime Minister's statement CQC response NHS Choices assessment King's Fund response NHS Commissioning Board response BMJ Feature PCC report: Implications for CCGs and general practice NHS Confederation

Other reference (1)

NHS Choice webpage

http://www.nhs.uk/news/2013/02February/Pages/Mid-Staffs-inquiry-calls-carefailings-a-disaster.aspx

Francis' presentation on the King's Fund (10mins)

http://www.kingsfund.org.uk/audio-video/robert-francis-lessons-stafford

Francis slides
http://www.kingsfund.org.uk/audio-video/robert-francis-lessons-staffordpresentation-slides

Guardian summary website

http://www.guardian.co.uk/society/blog/2013/feb/06/mid-staffordshire-nhs-trustinquiry-report-published-live#block-51127e16b5790c5937938a48

Other reference (2)

NeLM list of responses to the Francis report

http://www.nelm.nhs.uk/en/NeLM-Area/News/2013---February/06/Francis-reportReport-of-the-Mid-Staffordshire-NHS-Foundation-Trust-Public-Inquiry/

NHS Constitution
http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Document s/nhs-constitution-interactive-version-march-2012.pdf

Inquiry act 2005

http://www.legislation.gov.uk/ukpga/2005/12/crossheading/constitution-of-inquiry (Criticism of the Inquiry act 2005 http://publicinquiries.org/introduction/the_inquiries_act_2005)

Thank you for your attention!