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Feature Mid Staffs Inquiry

Who knew what, and when, at Mid Staffs?

BMJ 2013; 346 doi: (Published 06 February 2013) Cite this as: BMJ 2013;346:f726
  1. Philip Carter, producer1,
  2. Brian Jarman, director2
  1. 1 Empirica Films
  2. 2Dr Foster Unit, Faculty of Medicine, Imperial College, London
  1. Correspondence to: B Jarman b.jarman{at}

The Francis report into the appalling failings of care at Mid Staffordshire NHS Trust has finally been published. Philip Carter and Brian Jarman explain how events unfolded

The extensive hearings of the inquiry into failings of care at Mid Staffordshire NHS Trust give perhaps the most intimate insight into the workings of the modern NHS yet glimpsed by outsiders—but it makes for dismal reading.

The line that consistently emerged throughout the inquiry was that those responsible at the trust and in the wider NHS were simply unaware of the scale and extent of the problems on the wards of Stafford Hospital—at least until the Healthcare Commission investigation of 2008-09. But a close analysis of the evidence generated by the inquiry casts doubt on this version of events. Indeed, the evidence suggests that there were ample warnings for all to see, yet they were seemingly dismissed, discounted, and disregarded.

Early warnings

As early as 2001, there were warning signs about the quality of clinical performance at Mid Staffs. In January, the first annual Dr Foster Hospital Guide was published, providing adjusted hospital death rates. Dr Foster uses hospital standardised mortality ratios (HSMRs) to assess hospitals—those with a score of less than 100 have fewer deaths than expected, and those with a score of more than 100 have more than expected.

The 1998-99 HSMR for Mid Staffs was significantly higher than expected, at 108. It was to be the pattern for the coming years: the HSMRs from 2001-02 to 2007-08 were all significantly high (at the 95% confidence interval level).1

Over the course of the public inquiry, the importance attached to these HSMRs would become a central source of contention. But the inquiry also uncovered many other warning signs that went seemingly unheeded.

On 3 August 2001 the chief executive of the south …

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