The Mid Staffs scandal
BMJ 2013; 346 doi: https://doi.org/10.1136/sbmj.f941 (Published 21 February 2013) Cite this as: BMJ 2013;346:f941
- Isobel Weinberg, editor, Student BMJ
On 6 February the Francis report was published. It was the outcome of a public inquiry—lasting more than two years—into one of the NHS’s biggest scandals.
The stories of patient mistreatment at Stafford Hospital have become notorious. Patients and their families reported dirty wards, a lack of nursing care, and long waits for medical attention. Patients were left lying in their soiled bed sheets because they had not been taken to the toilet, and receptionists dealt with triage in the emergency department.1
The inquiry was set up in November 2010 to examine the failure of regulators to spot poor standards of care at the Mid Staffordshire NHS Foundation Trust. As well as patient reports of appalling conditions in the hospital, it also had 500 more deaths than would have been expected between 2005-6 and 2007-8.
Examples of neglect of patients include the story of Joan Morris, 83, who was treated at Stafford Hospital in 2006. Her family said that food and water were left out of reach and that Morris did not have a bath or shower in the month she was in hospital.2 The daughter of Ellen Linstead, 67, said that her mother contracted Clostridium difficile and meticillin resistant Staphylococcus aureus (MRSA) at Stafford Hospital and that she often had to wash faeces off her mother’s hands.
In March 2009 a report from the Healthcare Commission found the standard of care at Mid Staffordshire was “appalling.” An independent inquiry, chaired by Robert Francis, reported in February 2010 that failures in patient safety and care were caused by inadequate training of staff, staff cutbacks, and overemphasis on government targets. In November 2010 the public inquiry began, again chaired by Francis, with the remit of looking at the failings of the Mid Staffordshire NHS Trust within the context of the wider NHS system.
So what recommendations did Francis’s report make for doctors and other healthcare professionals? What must change in the NHS to ensure that such poor care and substandard management can never again go unnoticed for so long? Here, we summarise the key outcomes of the Francis report and its implications for doctors and the NHS.
What did the report recommend? (BMJ 2013;346:f847)
Clare Dyer, freelance journalist
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, said the report.1
Mid Staffordshire NHS Foundation 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, said the inquiry. 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 wellbeing.”
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.”
A single regulator
Patients should be supported to report non-compliance and whistleblowers should be protected, Francis said.
He 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.
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 duty of candour
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.
The prime minister, David Cameron, 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.”
Compassionate, caring, and committed
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.”
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.”
1 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. February 2013. www.midstaffspublicinquiry.com/report.
Who is to blame? (BMJ 2013;346:f849)
Zosia Kmietowicz, freelance journalist, BMJ
The widespread system failure at Mid Staffordshire NHS Trust makes the identification of individual people responsible a “futile exercise” because so many are accountable, said Robert Francis.1 Naming names would “risk perpetuating the illusion that removal of particular individuals is all that is necessary” and focusing on “blame will perpetuate the cycle of defensiveness, concealment, lessons not being identified, and further harm.”
Instead, he said, “it is far more effective to learn rather than to punish.” His criticisms target the organisations involved and only at the level of trust are individual people singled out for personal inadequacies.
Mid Staffordshire NHS Trust comes in for the most criticism. Leaders there “failed to appreciate the enormity of what was happening, reacted too slowly, if at all, to some matters of concern of which they were aware, and downplayed the significance of others.”
Martin Yeates, chief executive of the trust from September 2005 to March 2009, was described by Francis as “the most dangerous of leaders; one who was persuasive but ineffective.” Staff saw him as intimidating and unapproachable. He was intent on gaining foundation status for the trust and “was much better at giving an appearance of intent to address issues raised with him than he was at ensuring that the appropriate action was actually taken.”
John Newsham, the trust’s finance director, was blind to the impact of cost and staff cuts on patient care. Francis said, “His answers to my questions on this subject were profoundly unsatisfactory and showed no sign of acceptance that more should have been done.”
Toni Brisby, trust chairman from 2004 to March 2009, took a “particularly narrow view of her duties,” said Francis—which resulted in her distancing herself too much from how the trust was run and the effect on staff and patients, and failing to listen to complaints. Francis said she still cannot accept the findings from the Healthcare Commission and the first inquiry into the trust. He concluded that she “is a very dangerous person to be at the head of a service to patients.”
Val Suarez, medical director, knew about problems in surgery and the emergency department but failed to take action. “She may have acted no differently from many other medical directors faced with a similar problem, but it is a stark illustration of the need for medical professionals to refuse to tolerate situations which are unsafe for patients and of which they are aware,” said Francis.
West Midlands Strategic Health Authority, and Shropshire and Staffordshire Strategic Health Authority before it, failed to seek out or deal with patients’ safety concerns because they were too remote and too insensitive to the fact that patients could be at risk. Essentially, “failure of the leadership” was to blame.
Local GPs only expressed substantive concern about the quality of care at the trust after the Healthcare Commission’s investigation was announced. In the future, Francis said in his report that “They should exploit to the full this new role [as commissioners] in ensuring their patients get safe and effective care.”
Monitor should never have authorised the trust foundation status in 2008, said Francis. And its failure to spot deficiencies at the hospital “calls into question the effectiveness of the foundation trust regulatory system as a whole.” He added, “It has to be questioned whether the system could reliably detect concerns relevant to patients of any significant nature, if it could not detect a case as gross as that of the trust.”
The Healthcare Commission was the first organisation to expose the scandal, which it did in March 2009, but it “failed to prevent or detect over three quarters of its lifetime what has been described as the biggest scandal in NHS history,” said Francis. He stated that the organisation relied too much on “self assessment and self declaration as the basis of regulation.”
The Department of Health failed to recognise that imposing structural change on health authorities, primary care trusts, and trusts made it more difficult to focus on quality of care and patient safety. “It is not possible to avoid the impression that it lacks a sufficient unifying theme and direction, with regard to patient safety, to move forward from this point in spite of the recent reforms put in place by the current government,” said the report. It has failed to put quality “at the core of its policy”.
Deaneries and universities failed to detect that anything was wrong at Stafford Hospital and acted too slowly when poor standards of care were discovered. “The oversight of medical training should not condone or support unacceptable practice.”
The Royal College of Nursing, at Stafford, was “ineffective both as a professional representative organisation and as a trade union. Little was done to uphold professional standards among nursing staff or to address concerns and problems being faced by its members.”
1 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. February 2013. www.midstaffspublicinquiry.com/report.
What could doctors do better? (BMJ 2013;346:f848)
Gareth Iacobucci, news reporter, BMJ
Robert Francis stated that doctors, as well as managers and regulatory bodies, must also accept some portion of responsibility. “The local medical community did not raise concerns until it was too late,” he said.
The report itself said: “Consultants at Stafford were not at the forefront of promoting change . . . clinicians did not pursue management with any vigour with concerns they may have had. Many kept their heads down. A degree of passivity about difficult personnel issues is all too common in the NHS as, perhaps, elsewhere. However, a system that is safe for patients requires a much more rigorous approach.”
Recommendations put forward by Francis includes hospitals considering reinstating the practice of identifying a senior clinician to be in overall charge of each patient’s care, to ensure that patients have a direct point of contact if they want to complain about the quality of care they receive.
It said that GPs should have a greater role in monitoring their patients who receive acute and specialist care, and should develop “internal systems” that allow them to track patterns of concern, rather than merely treating each case “on its individual merits.”
Changes to medical training and education are advised, including for the General Medical Council to amend its standards for undergraduate medical education to have a requirement for providers to “actively seek feedback from students and tutors” on how providers are complying with minimum standards of patient safety and quality of care.
Whistleblowing allowed
The BMA’s chairman, Mark Porter, said in response to the report: “Unless and until medical staff and management jointly promote the ethos that raising concerns is not only acceptable but a positive thing, the shadow of Mid Staffs will put us all into darkness. Doctors, along with other clinical staff, have a professional responsibility to show leadership in helping to change this culture. We must no longer accept the attitude that it is someone else’s job to worry about.”
Porter called for a new culture to be adopted by doctors and managers in the NHS that showed “zero tolerance to poor and dangerous care.”
The government response (BMJ 2013;346:f840)
Adrian O’Dowd, freelance journalist, London
David Cameron made a statement in the House of Commons shortly after the Francis report was published, and expressed his anger at what transpired at Mid Staffordshire NHS Trust.
“Too many doctors kept their heads down instead of speaking out when things went wrong,” said Cameron. “However, the Francis report says we should not seek scapegoats.” Cameron has promised action to prevent the “horrific abuse” that took place there from happening again. He announced that he had asked the NHS’s main regulator, the Care Quality Commission, to create a new post of chief inspector of hospitals by the autumn.
The prime minister said that the government would study all 290 recommendations made in the report and respond in detail next month.
In the meantime, however, some steps could be taken, and he announced that the government would create a single failure regime for trusts under which a trust board could be suspended for failures in care as well as for financial failures.
Cameron said that he favoured the approach that staff pay should be linked to the quality of care provided rather than to time served in a hospital.
The regulators were heavily criticised by the prime minister, who said: “What happened within the Stafford Hospital should have led to those who were responsible being brought to book. This didn’t happen.
“I believe the regulatory bodies in particular are going to have some difficult questions to answer. The Nursing and Midwifery Council and the General Medical Council need to explain why so far, no one has been struck off.
Mid Staffordshire—what happened when (BMJ 2013;346:f72)
Zosia Kmietowicz, freelance journalist, BMJ
Apr 2007: West Midlands Strategic Health Authority’s board, chaired by Cynthia Bower, discusses data from the healthcare information company Dr Foster showing that six hospitals in the area had high mortality rates. Board agrees to write to Dr Foster and to commission a report into Dr Foster’s methods from the University of Birmingham.
Jun 2007: Mid Staffordshire’s application to become an NHS foundation trust goes to the regulator Monitor. Andy Burnham, health minister, says, “I am delighted that Mid Staffordshire General Hospitals NHS Trust has now reached a high enough standard to be considered as an NHS foundation trust . . . I would like to congratulate all of the staff of the trust on this achievement.”
Jul 2007: Dr Foster starts to send letters to Mid Staffordshire’s chief executive, Martin Yeates, warning of higher than expected mortality.
2007: Royal College of Surgeons writes a highly critical report on surgery at the trust but fails to check that its recommendations are followed up.1
Feb 2008: Mid Staffordshire is granted foundation status by Monitor. Ben Bradshaw, a health minister at the time, told the Francis inquiry in September 2011 that this was “already a disaster.”2
Jun 2008: University of Birmingham publishes its report, concluding that Dr Foster mortality figures were not fit for purpose. This is subsequently published in BMJ.3
Mar 2009: Healthcare Commission finds “appalling” standards of care at Mid Staffordshire. Management had “significantly” reduced staff in a bid to save money in its drive to become a foundation trust, which resulted in higher than normal death rates in emergency department, with an increasing trend from 2005 to early 2007. Death rates for diabetes, epilepsy or convulsion, and repair of abdominal aortic aneurysm were also significantly high.4 Figures leaked later indicated that there had been between 400 and 1200 excess deaths at the trust’s Stafford Hospital between 2005 and 2008.5
Apr 2009: Trust calls in a team from Royal College of Surgeons. This time the college found that the surgery service was “inadequate, unsafe, and, at times, dangerous.” Gall bladder surgery was found to have a death rate 10-15 times as high as expected. Report was not made public till March 2011, as part of the public inquiry.6
Nov 2009: Dr Foster Intelligence publishes its Good Hospital Guide, based on 2008-9 data, rating Mid Staffordshire among the highest performing hospitals in England, with the best improvement in hospital standardised mortality ratio over the previous three years of any hospital. The improvement turns out to be largely based on coding changes that flattered the trust’s mortality figures.
Feb 2010: An independent inquiry, chaired by Robert Francis QC (the Francis report), found that appalling failures in patient safety and care were caused by inadequate training of staff, staff cutbacks, and overemphasis on government targets by the trust’s senior management. Francis said that senior managers had ignored concerns raised by many staff.7
Mar 2010: Mid Staffordshire is granted limited registration by the Care Quality Commission (CQC) under the new tougher system for regulating standards in the NHS. The commission found that the trust had not complied with six of the 16 essential standards of safety and quality. There was still a deficit in nursing staff of 11% at the end of January 2010.8
Nov 2010: Public inquiry into failings at the trust starts, chaired by Francis. It aims to learn wider lessons from the failure of regulators to spot poor standards of care at Stafford Hospital.
Oct 2011: CQC issues formal warning to Stafford Hospital that staff shortages could still be endangering the safety and welfare of patients in the emergency department.9
Nov 2011: Two army emergency doctors and four nurses are drafted in to plug staff shortages threatening safety at Stafford Hospital’s emergency department, which has only four of its complement of six consultants. Thought to be the first time this has happened.10
Feb 2012: Cynthia Bower resigns from her post as CQC chief executive after a damning report from the Department of Health on the failure of the commission. She was previously chief executive of NHS West Midlands, the strategic health authority responsible for Stafford Hospital when the scandal emerged.11
2012: A coalition of 150 charities publishes Not the Francis Inquiry, calling for urgent action to prevent another scandal like that at Mid Staffordshire on the day the public inquiry was due to be published (15 October).12
Feb 2013: Francis publishes the report of his public inquiry into the events at Stafford Hospital.
1 Dyer C. Royal College of Surgeons failed to follow up its critical report on Mid Staffordshire trust, inquiry hears. BMJ 2011;343:d4189.
2 Dyer C. Former health minister questions why GPs did not sound alarm bells about Stafford hospital. BMJ 2011;343:d5744.
3 Mohammed MA, Deeks JJ, Girling A, Rudge G, Carmalt M, Stevens AJ, et al. Evidence of methodological bias in hospital standardised mortality ratios: retrospective database study of English hospitals. BMJ 2009;338:b780.
4 Mashta O. Hospital trust sacrificed patient care to financial matters, commission says. BMJ 2009;338:b1141.
5 Dyer C. Head of Healthcare Commission excised figures on excess deaths from Mid Staffordshire report. BMJ 2011;342:d2900.
6 Dyer C. Report reveals Stafford hospital surgery team was “dysfunctional” and “frankly dangerous.” BMJ 2011;342:d1581.
7 Mooney H. Poor training, staff cuts, and over emphasis on targets led to failures at Stafford hospital, says inquiry. BMJ 2010;340:c1137.
8 Wise J. Mid Staffordshire and Milton Keynes are granted conditional registration. BMJ 2010;340:c1608.
9 Dyer C. Stafford Hospital receives formal warning from regulator. BMJ 2011;343:d6562.
10 Dyer C. Army medical staff plug shortages in accident and emergency department at Stafford Hospital. BMJ 2011;343:d7566.
11 Hawkes N. Head of healthcare watchdog resigns after series of damming reports. BMJ 2012;344:e1396.
12 O’Dowd A. Charities demand urgent steps to prevent another Mid Staffordshire scandal. BMJ 2012;345:e6956.
Links
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Notes
Originally published as: Student BMJ 2013;21:f941
Footnotes
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.