Stafford inquiry will probe why external supervision failed

A public inquiry that opened this week will learn NHS-wide lessons from the scandal of Stafford Hospital, the lawyer chairing the inquiry pledged.

Investigations into the hospital, run by Mid Staffordshire NHS Foundation Trust, found that patients received “appalling” care and that more than 400 excess deaths occurred between 2005 and 2008.

Opening the inquiry, its chairman, Robert Francis QC, said it was important to “keep at the forefront of our minds the terrible effect of the system’s failings on those it was meant to serve.” Mr Francis said he had listened to “many stories of appalling care” during the inquiry he conducted last year into failings at the hospital, which heard evidence in private.

“As I did so, the questions that went constantly through my mind were: why did none of the many organisations charged with the supervision and regulation of our hospitals detect that something so serious was going on, and why was nothing done about it?”

Among those expected to face public questioning are former health secretaries for England Alan Johnson and Andy Burnham, who were in office during the previous Labour government. They commissioned investigations into the scandal but refused relatives’ demands for a public inquiry.

Last June, after the Conservative and Liberal Democrat coalition government took office, the new health secretary, Andrew Lansley, ordered the latest inquiry, which has power to compel witnesses to attend and give evidence. He told parliament, “We know only too well what happened at Mid Staffordshire, in all its harrowing detail, and the failings of the trust itself. But we are still little closer to understanding how it was allowed to happen by the wider system.

“When this inquiry has completed its work and I return to this house to present its report, I am confident that we will, for the first time in this tragic saga, be able to discuss conclusions rather than questions.”

Mr Francis, who will be working with four assessors, is due to hear evidence from the NHS’s top management, including David Nicholson, the NHS’s chief executive; Bruce Keogh, its medical director; and Liam Donaldson, former chief medical officer for England.

Witnesses are also expected to include the heads of several regulators, including Cynthia Bower, now chief executive of the Care Quality Commission. Between July 2006 and July 2008 she was chief executive of NHS West Midlands, the strategic health authority responsible for overseeing Stafford Hospital.

Mr Francis said he would look at “why the system of NHS management and regulation external to the trust did not detect or act on the deficiencies before the intervention of the Healthcare Commission in 2008-9. There was clearly cause for concern before that action was taken.”

He said he had been set a “truly formidable and complex” task, with more than a million pages of documentation to review, but that he hoped to finish most of the oral hearings by mid-2011.

The Healthcare Commission found that patients were neglected as management concentrated on meeting targets and on saving money (BMJ 2009;338:b1141, doi:10.1136/bmj.b1141). The accident and emergency department was “fraught with hazards” for patients admitted there, as was the emergency assessment unit, the commission said.

As the inquiry opened, the College of Medicine, a new alliance of doctors, scientists, and patients (BMJ 2010;341:c6126, doi:10.1136/bmj.c6126), called on the government to ensure that every NHS trust appoints a safety officer to protect patients from “institutionalised neglect and abuse.”