Organisations not individual people are to blame, says Francis

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 QC in his report into the public inquiry.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.”

David Newsham, the trust’s finance director, was blind to …