Intended for healthcare professionals


Culture change: Robert Francis’s prescription for the NHS

BMJ 2013; 346 doi: (Published 13 February 2013) Cite this as: BMJ 2013;346:f979

Re: Culture change: Robert Francis’s prescription for the NHS

Tony Delamothe says we have known for several years that an extra 500 deaths occurred at Stafford Hospital between 2005-06 and 2007-08 and implies this was due to the "appalling examples of nursing care". The references he gives are the Heathcare Commission investigation and Robert Francis' first inquiry report.

Actually, in Appendix 9 of volume 1 of the first report, Francis wrote "It is unfortunate that the figure of 400-1200 excess deaths became so widely publicized and sensationalized". There were fears that the public would not understand 95% confidence intervals around standardised mortality ratios.

Unfortunately, Francis' more recent report has not stemmed such sensationalism. For example, a Sun correspondent recently reported that, "Up to 1,200 patients died needlessly between January 2005 and March 2009".[1] Even Rebecca Coombes in the BMJ says that Francis' 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 ... “horrific abuse.”"

There were, of course, hospitals with worse HSMRs than Stafford hospital. What Francis says in the latest report is that "a high rate of “unexpected” deaths cannot be translated into a number of “avoidable” deaths, any more than a low rate of such deaths means that all is well." He makes clear he has not suggested that any specific number or proportion of deaths was from an avoidable cause. Nonethless, his wish to avoid scapegoating of individuals by emphasising institutional failure, may well have meant he has scapegoated the hospital itself (see



Competing interests: No competing interests

17 February 2013
D B Double
Consultant Psychiatrist
Norfolk & Suffolk NHS Foundation Trust
Victoria House, 28 Alexandra Road, Lowestoft NR32 1PL