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Feature Mid Staffs Inquiry

How the message from mortality figures was missed at Mid Staffs

BMJ 2013; 346 doi: (Published 30 January 2013) Cite this as: BMJ 2013;346:f562
  1. Nigel Hawkes, freelance journalist
  1. 1London, UK

Do published outcomes tell us what’s really going on inside a hospital? Nigel Hawkes reports on how standardised mortality ratios at Mid Staffordshire NHS Foundation Trust came to conceal the hospital’s failings

The new NHS in England aims to empower the patient and shame failing hospitals by measuring and publishing outcomes. Open data will make health providers honest and patients better able to choose between them. How simple is that?

Rather too simple, to judge by evidence presented to the public inquiry into Mid Staffordshire NHS Foundation Trust, which has shown that the old NHS had ingenious ways of burnishing its outcomes and concealing its failings. Even death, the most unambiguous outcome of all, lost its sting when changes in coding practice resulted in many deaths being excluded from the calculation of hospital mortality ratios.

Whether this amounted to actual dishonesty may never be determined. In his final submission Tom Kark, counsel to the inquiry, suggested that it may not be necessary for Robert Francis, the inquiry’s chair, to make any finding of fact over claims that Mid-Staffs and two other West Midlands trusts engaged in a plan to lower their apparent mortality ratios by changing the way patients were coded.1 Nor did Kark reach any firm conclusion over the suggestion that West Midlands Strategic Health Authority (SHA) sought to muddy the waters by commissioning a critical report into mortality measures, published in the BMJ, from academics known to disbelieve in the method.

Both these charges were made in evidence to the inquiry by Professor Brian Jarman, the father of the hospital standardised mortality ratio (HSMR, see box), which has been used for the past decade by the health analytics company Dr Foster to compare hospital performance. By his reckoning, West Midlands tried to undermine the mortality data …

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