Intended for healthcare professionals


NHS must adopt a culture of “zero tolerance” for patient harm, Francis report says

BMJ 2013; 346 doi: (Published 06 February 2013) Cite this as: BMJ 2013;346:f847
  1. Clare Dyer
  1. 1BMJ

The NHS must be transformed into a patient centred culture with “zero tolerance” for patient harm and criminal sanctions for failure to provide safe care, a landmark report into one of the health service’s biggest scandals has recommended.1

The public inquiry into Mid Staffordshire NHS Foundation Trust found failures at every level up to and including the Department of Health, which together allowed “terrible and unnecessary suffering” by patients to go undetected for years.

The trust, which ran Stafford and Cannock Chase hospitals, was intent on meeting targets set by the NHS and qualifying for the status of foundation trust, focusing on corporate governance and financial control. But patient safety and care were ignored, and there were nearly 500 excess deaths between 2005 and 2008, although signs that should have raised concerns were present years before.

Patients “were failed by a system which ignored the warning signs of poor care and put corporate self interest and cost control ahead of patients and their safety,” said inquiry chairman Robert Francis QC.

“There was an institutional culture in which the business of the system was put ahead of the priority that should have been given to the protection of patients and the maintenance of public trust in the service.”

Patients’ voices were not heard, local GPs failed to raise concerns, primary care trusts did not have the tools to ensure the quality of the services they were buying, the strategic health authority defended trusts rather than holding them to account, and the Department of Health was “remote from the reality of the service at the front line,” said Francis. “At every level there was a failure to communicate known concerns adequately to others, and to take sufficient action to protect patients’ safety and well being.”

But he said “the last thing” needed was more radical reorganisation in the NHS, which has struggled to cope with a series of reorganisations in recent years. What was required instead was “a structure of clearly understood fundamental standards and measure of compliance, accepted and embraced by the public and healthcare professionals, with rigorous and clear means of enforcement.”

The National Institute for Health and Clinical Excellence should produce standard procedures, guidance, and assessment tools, including guidance on levels of nursing and clinical staff. Patients should be supported to report non-compliance and whistleblowers should be protected, he said.

Francis called for a single regulator to ensure that the fundamental standards are complied with. Despite criticisms of the Care Quality Commission, which he said had shown “a defensive institutional instinct to attack those who criticise it,” he recommended that it should police standards following the implementation of a range of recommendations to strengthen it. Commissioners of healthcare services should develop enhanced standards and ensure these were delivered by providers.

Services that failed to meet fundamental standards should be suspended and criminal prosecutions should be possible where a patient has died or suffered serious harm as a result of a breach of fundamental standards, he recommended. Where individual doctors or other professionals breached fundamental standards, they should face action by professional regulators such as the General Medical Council.

A common culture of serving and protecting patients and rooting out poor practice could not be achieved without openness, transparency, and candour throughout the system, Francis said. He recommended a statutory duty of candour for NHS providers and professional staff.

This would oblige healthcare providers, including GPs and hospital trusts, who believed or suspected that treatment or care they provided caused death or serious harm to tell the patient or, in the case of a death, the nearest relative. Doctors or nurses who were employees would have to report their belief or suspicion to their employer.

There would be a statutory duty on directors of healthcare organisations to be truthful in any information given to a regulator or commissioner, and it would be a criminal offence for a doctor or nurse to dishonestly make an untruthful statement to a regulator or commissioner or to provide information to a patient or nearest relative that was intended to mislead.

The prime minister, David Cameron, announced the creation of a new post of chief inspector of hospitals. He apologised to patients for treatment that was “not just wrong, it was truly dreadful,” and promised to “look very carefully” at the idea of a statutory duty of candour. The health secretary, Jeremy Hunt, said he was “sympathetic” to the proposal.

Peter Walsh, chief executive of Action against Medical Accidents, welcomed the recommendation, for which the organisation has long campaigned. He said, “The government must now accept the recommendation for a legal duty of candour which would represent the biggest advance in patient safety and patients’ rights in the history of the NHS. So far they have fiercely resisted this.”

At Mid Staffordshire, there was “a lack of care, compassion, and leadership,” said Francis. “Elderly and vulnerable patients were left unwashed, unfed, and without fluids. Some patients had to relieve themselves in their beds when they were offered no help to get to the bathroom. Some were left in excrement stained sheets and beds. Medicines were prescribed but not given.”

The report recommends a range of reforms to ensure “compassionate caring and committed nursing,” including better assessment of entrants, more training of nurses in hands-on patient care, and a registration system for healthcare assistants.

Doctors and nurses who are managers can be disciplined by their regulators if they fail to protect patients, but other managers cannot, Francis pointed out. He called for a leadership staff college, a code of conduct and registration scheme for managers, and a requirement that only fit and proper persons can be directors of NHS organisations.

He said, “We need to ensure fundamental standards are enforceable by law, and the criminal law in the most serious of cases. Senior managers should be made accountable, patients need to be protected from poor nursing standards and all staff should be empowered to be open and transparent when it comes to the wellbeing of the people in their care.”

The NHS Commissioning Board promised “fundamental change” in response to the report and announced an immediate investigation into five hospitals which had high death rates on the Summary Hospital-level Mortality Indicator for two successive years to 2012.

Groups representing patients, doctors, and healthcare organisations welcomed the report. Mike Farrar, chief executive of the NHS Confederation, representing all organisations that commission and provide NHS services, commented on its “hard-hitting but fair analysis.”

He added, “There are real opportunities in the newly emerging NHS to do things differently. We need to shine a light into every corner of the NHS, giving patients more information and power over their local services. We must improve the culture in our organisations, embedding the core NHS values of care and compassion and making these a basic requirement for everyone working in the health service.”

The BMA pledged to “do all it can to work with others in developing a new culture in the NHS to prevent similar catastrophes happening in future.”

NHS Clinical Commissioners, on behalf of clinical commissioning groups, said, “We will use the intelligence we have, both hard and soft: incident reports, trends, patient feedback as well as data published by providers to shine a spotlight, address failures and use our position to drive up quality throughout the system.”


Cite this as: BMJ 2013;346:f847


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