Most of the UK media has reported on the Francis inquiry into significant failures in care at the Mid Staffordshire NHS Foundation Trust.
The report suggests a raft of radical changes to help improve patient safety. These include proposals to make serious but avoidable medical mistakes a criminal offence.
The Healthcare Commission (the hospital regulator at the time) first raised concerns about the trust in 2007, after determining it had unusually high death rates.
These concerns led to a series of reports, undertaken by different bodies, which all found widespread evidence of significant failures in care, including:
This current inquiry was commissioned in 2010 to investigate wider issues that may have contributed towards these serious problems. The inquiry, carried out by the barrister Robert Francis QC, was asked to come up with recommendations which could help prevent similar failings from happening in the future.
The findings of the inquiry have now been published.
The findings of the inquiry can fairly be described as damning. It highlights what amounts to a ‘perfect storm’ of systematic failures of care at multiple levels, including:
Mr Francis concludes that, ‘The extent of the failure of the system shown in this report suggests that a fundamental culture change is needed. This does not require a root and branch reorganisation – the system has had many of those – but it requires changes which can largely be implemented within the system that has now been created by the new reforms.’
The inquiry makes a total of 290 individual recommendations. These include:
The final report of the public inquiry has now been published, and the government has said it will respond to the recommendations of the inquiry in March 2013. Changes required by earlier reports into the failings at Mid Staffs are already underway.
The Prime Minister David Cameron has said that “quality of care” should be on a par with “quality of treatment”.
He said: “We have set this out explicitly in the Mandate to the NHS Commissioning Board, together with a new vision for compassionate nursing.
“We have introduced a tough new programme for tracking and eliminating falls, pressure sores and hospital infections.
“And we have demanded nursing rounds every hour, in every ward of every hospital.”