Inability to detect failures at Mid Staffs means it could happen again, Francis concludes

BMJ 2013; 346 doi: (Published 07 February 2013) Cite this as: BMJ 2013;346:f853
  1. Nigel Hawkes
  1. 1London

In his report into Mid Staffordshire NHS Foundation Trust Robert Francis avoids blaming individuals for what took place. But he also accepts the corollary of this judgment: if the failures were not a unique event caused by a few rogue staff, then it is difficult to have any confidence that it could not happen again.

Even if it were true that no other healthcare providers showed the same combination of deficiencies, he said, “it is of grave concern that the extensive system of checks and balances intended to detect such failures did not work.”1 Since the Healthcare Commission reported into Mid Staffs in March 2009, there had been, he said, a number of other critical reports of NHS services. Even if all the instances were in some way isolated ones that depended on particular circumstances, he said, “they are suggestive that there are other places where unhealthy cultures, poor leadership, and an acceptance of poor standards are too prevalent.”

The failure of the systems to detect deficiencies meant, he said, that the public was unlikely to have confidence that “another Stafford” did not exist. “Stafford was not an event of such rarity or improbability that it would be safe to assume that it has not been or …

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