Robert Francis is a lawyer and therefore careful with his words and not prone to soundbites. It took him four volumes and 2000 pages to sum up his findings on Wednesday. His report unpicked an NHS culture that tolerated such appalling low standards of care at Stafford Hospital that 400-1200 patients died of neglect, misdiagnosis, and, to quote prime minister David Cameron, “horrific abuse.”

Speaking to the BMJ, Francis is clear that doctors at the hospital were part of this culture. Asked what doctors should take from his report, he says: “A consultant has a personal professional responsibility for the welfare of their patient, not just their liver and appendix or whatever, and if that consultant turns up [on the ward] and sees that the care being given to that patient is unsatisfactory then they have to do something about it. I suspect many do, but it’s a regrettable fact that some consultants at Stafford cannot have been doing that otherwise these things would have been spotted and stopped.”

In his first inquiry into the Mid Staffs scandal Francis identified a “fatalistic” attitude among doctors; they had lost faith in management, kept their head down, and got on with their job. This theme surfaced again in his final inquiry: “Clinicians did not pursue management with any vigour with concerns they may have had. Many kept their heads down,” …