Learning the lessons from Stafford failings

 As HEJ editor, Jonathan Baillie reports, they will make uncomfortable reading for a wealth of different organisations – from the Trust itself to the Care Quality Commission, Monitor, the Department of Health, the West Midlands Strategic Health Authority, and The Health Protection Agency, and well also cause significant concern within the nursing and clinical professions.

In publishing the report, on 6 February, the Inquiry team said their investigation – the fifth to date into care standards at a hospital where, it is suggested, there were between 400 and 1,200 more deaths between 2005 and 2008 than might have been expected for a facility and local population of this type – had identified ‘a story of terrible and unnecessary suffering of hundreds of people who 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’. The latest ‘Francis Report’, entitled Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, was produced following the Inquiry team’s detailed consideration of evidence from over 250 witnesses, and scrutiny of more than a million pages of documentary material, collected between November 2010 and December 2011. The Report summarises the team’s resulting conclusions and findings on why the ‘serious problems’ at the Mid Staffordshire Hospital NHS Foundation Trust, and at Stafford Hospital in particular, were not picked up and acted on sooner. The Inquiry, which has also sought to identify ‘important lessons to be learned for the future of patient care’, builds on Robert Francis’s earlier report, which was published in 2010 after an earlier independent inquiry on the ‘failings’ at the Trust over a four-year period.

A raft of factors to blame