Organisations not individual people are to blame, says Francis

BMJ 2013; 346 doi: (Published 06 February 2013) Cite this as: BMJ 2013;346:f849
  1. Zosia Kmietowicz
  1. 1BMJ

The widespread system failure at Mid Staffordshire NHS Trust makes the identification of individual people responsible a “futile exercise” because so many are accountable, said Robert Francis QC in his report into the public inquiry.1 Naming names would “risk perpetuating the illusion that removal of particular individuals is all that is necessary” and focusing on “blame will perpetuate the cycle of defensiveness, concealment, lessons not being identified, and further harm.”

Instead, he said, “it is far more effective to learn rather than to punish.” His criticisms target the organisations involved and only at the level of trust are individual people singled out for personal inadequacies.

Mid Staffordshire NHS Trust comes in for the most criticism. Leaders there “failed to appreciate the enormity of what was happening, reacted too slowly, if at all, to some matters of concern of which they were aware, and downplayed the significance of others.”

Martin Yeates, chief executive of the trust from September 2005 to March 2009, was described by Francis as “the most dangerous of leaders; one who was persuasive but ineffective.” Staff saw him as intimidating and unapproachable. He was intent on gaining foundation status for the trust and “was much better at giving an appearance of intent to address issues raised with him than he was at ensuring that the appropriate action was actually taken.”

David Newsham, the trust’s finance director, was blind to the impact of cost and staff cuts on patient care. Francis said, “His answers to my questions on this subject were profoundly unsatisfactory and showed no sign of acceptance that more should have been done.”

Toni Brisby, trust chairman from 2004 to March 2009, took a “particularly narrow view of her duties,” said Francis—which resulted in her distancing herself too much from how the trust was run and the effect on staff and patients, and failing to listen to complaints. Francis said she still cannot accept the findings from the Healthcare Commission and the first inquiry into the trust. He concluded that she “is a very dangerous person to be at the head of a service to patients.”

Val Suarez, medical director, knew about problems in surgery and the emergency department but failed to take action. “She may have acted no differently from many other medical directors faced with a similar problem, but it is a stark illustration of the need for medical professionals to refuse to tolerate situations which are unsafe for patients and of which they are aware,” said Francis.

West Midlands Strategic Health Authority, and Shropshire and Staffordshire Strategic Health Authority before it, failed to seek out or deal with patients’ safety concerns because they were too remote and too insensitive to the fact that patients could be at risk. Essentially, “failure of the leadership” was to blame.

Local GPs only expressed substantive concern about the quality of care at the trust after the Healthcare Commission’s investigation was announced. In the future, Francis said in his report that “They should exploit to the full this new role [as commissioners] in ensuring their patients get safe and effective care.”

Primary care trusts took “undue comfort” from the assumption that others had responsibility for quality of care so ignored this issue, although they may not have been different to similar trusts in other parts of the country.

Monitor should never have authorised the trust foundation status in 2008, said Francis. And its failure to spot deficiencies at the hospital “calls into question the effectiveness of the foundation trust regulatory system as a whole.” He added, “It has to be questioned whether the system could reliably detect concerns relevant to patients of any significant nature, if it could not detect a case as gross as that of the trust.”

The Healthcare Commission was the first organisation to expose the scandal, which it did in March 2009, but it “failed to prevent or detect over three quarters of its lifetime what has been described as the biggest scandal in NHS history,” said Francis. He stated that the organisation relied too much on “self assessment and self declaration as the basis of regulation.”

The Care Quality Commission had a difficult job but it was not “a happy environment to work in,” said the report. Francis described it as having “a defensive institutional instinct to attack those who criticise it” and one which did not listen to patients’ concerns. It also criticised its regulatory requirements which combine a number of different concepts, such as safety and welfare.

The Department of Health failed to recognise that imposing structural change on health authorities, primary care trusts, and trusts made it more difficult to focus on quality of care and patient safety. “It is not possible to avoid the impression that it lacks a sufficient unifying theme and direction, with regard to patient safety, to move forward from this point in spite of the recent reforms put in place by the current government,” said the report. It has failed to put quality “at the core of its policy by assessing the impact of key policies, such as financial rebalance, the FT [foundation trust] agenda and structural reform on quality.” Officials are too remote from what is happening on the frontline and do not always put patients first. Although the department is not a bully, “well intentioned decisions and directives emanating from the DH [Department of Health] have either been interpreted further down the hierarchy as bullying, or resulted in them being applied locally in an oppressive manner,” said Francis. Senior clinicians needed to be at the heart of decision making on key issues.

The General Medical Council and Nursing and Midwifery Council had inconsistent outcomes because of the nature of their individual approaches to sanctions. “Both organisations need to develop their capacity to examine and investigate concerns even where no named individual has been identified to them,” said Francis.

Deaneries and universities failed to detect that anything was wrong at Stafford Hospital and acted too slowly when poor standards of care were discovered. “The oversight of medical training should not condone or support unacceptable practice.”

The Health Protection Agency did not escalate its concerns about infection control at the trust promptly to the Healthcare Commission or the health authority. “Organisational boundaries and cultures should not prevent the use by all of information and advice designed to enhance patient safety,” said the report.

The Health and Safety Executive does not maintain public confidence. It looks for “reasons for not taking action rather than starting from a consideration of what is in the public interest.” There is a regulatory gap between the executive and the Care Quality Commission as to who should investigate individual breaches of safety, some of which may require criminal sanction, said Francis.

The Royal College of Nursing, at Stafford, was “ineffective both as a professional representative organisation and as a trade union. Little was done to uphold professional standards among nursing staff or to address concerns and problems being faced by its members.”


Cite this as: BMJ 2013;346:f849