Last reviewed 12 March 2013

The long-awaited inquiry into the deaths of patients at Mid Staffordshire NHS Foundation Trust by Robert Francis QC was published on 6 February 2013. Thoreya Swage examines it in detail.

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, which investigated between 400 and 1200 deaths at the Trust from 2005 to 2009, is just under 2000 pages in length, is spread over three volumes and has 290 recommendations. It catalogues the many failures of the NHS managers and regulators in identifying the poor standards of patient care and there will be repercussions for the individuals and institutions that were involved during the four years in question.

Although the focus of the report and recommendations are towards hospital care, lessons can be learnt and proactive action can be initiated in primary care to ensure that failures of care could not be repeated in other healthcare settings. In order to understand this, it is pertinent to examine some of the key recommendations.

The inquiry

The inquiry, costing £13 million, was conducted for 139 days over the course of a year, hearing evidence from 352 witnesses. Key witnesses, in addition to patients and their relatives, included Sir David Nicholson, Chief Executive of the NHS; Peter Carter, Chief Executive of the Royal College of Nursing (RCN); Peter Walsh, Chief Executive of Action Against Medical Accidents; Professor Sir Ian Kennedy, former Chair of the Healthcare Commission (HCC); Niall Dickson, Chief Executive of the General Medical Council; managers of Mid Staffordshire Foundation Trust, the Primary Care Trust (PCT) and the Strategic Health Authority (SHA), and local GPs.

The focus of this inquiry was to examine the role of external bodies in relation to their ability to identify and monitor hospitals that were failing to provide appropriate care. This included organisations such as the Care Quality Commission (CQC) — the Healthcare Commission (HCC) as was — the PCT, SHA and Monitor, as well as the board of the Foundation Trust itself.

Following the end of the public hearings, seven seminars were set up in order to discuss various topics identified by the inquiry, including:

  • options for methods of regulation

  • training and development of managers and board members who lead trusts

  • information and patient experience

  • nursing and organisational culture

  • commissioning.

The findings

The main findings were as follows.

  • There was a consistent comment from managers involved with the Trust and other outside bodies that concerns were not drawn to their attention during the period under investigation.

  • However, during the period in question, in 2004 when the Trust’s star rating was changed from three stars to zero by the HCC, the Shropshire and Staffordshire SHA was aware of this situation in that targets for elective surgery, outpatient and cancer waiting times and financial performance were not being met.

  • Peer reviews conducted during 2005 and 2006, including a cancer peer review and a critically ill and critically injured children peer review, highlighted serious concerns about the Trust’s ability to provide a safe service and the management capability. However, it was not clear whose responsibility it was to follow up such reports and to implement remedial action plans.

  • The HCC conducted its own review into children’s services nationally in 2006 and came to the same conclusion with regard to the Trust. The Trust responded indicating that this was due to poor data collection and developed an action plan for improvement.

  • Various auditors’ reports presented to the Trust board identified serious concerns about the Trust’s risk management systems and assurance processes. This finding should have raised alarms to outside bodies such as Monitor, the CQC and the Department of Health (DH) as to the leadership and management capability and competence within the Trust.

  • Patient surveys conducted on behalf of the HCC by the Picker Institute in 2007 rated the Trust in the worst performing 20% in England.

  • In 2007, a report was made by a staff nurse about the leadership of the accident and emergency (A&E) department, which was not investigated by the management of the Trust, and a Royal College of Surgeon’s report described the surgical unit management processes as “dysfunctional”. Neither of these concerns was made known to other bodies, eg CQC or patient organisations, outside of the Trust or the Royal Colleges themselves.

  • The Trust was obliged to have a financial recovery plan as part of its application to become a Foundation Trust. In this plan, substantial cuts were made to staffing levels on top of the known concerns about the levels of service currently provided. There was no evidence of any scrutiny of the impact of such cuts on the quality of patient care.

  • During the Foundation Trust application process, while the emphasis was mainly on financial viability, concerns were raised by Monitor about the ability to maintain adequate levels of patient care. This was not acted upon by the SHA. Despite this, these concerns were known to the organisation and new management was in place in the Trust.

  • Throughout the Foundation Trust application process, the HCC was aware that the Trust was undergoing this procedure and Monitor was not aware of the service quality issues raised by the HCC until after Foundation Trust status was granted.

The key issues arising from the investigation

A negative culture

The problems at the Trust were not acted on by the Trust board, which was more focused on meeting financial targets and had an inaccurate view of performance. There was a denial of concerns that was compounded by ignorance of good practice carried out elsewhere.

Disengagement of professionals

The consultants within the Trust did not raise concerns in a consistent manner with managers and were disengaged. There was a lack of sense of responsibility at all levels to delivering good-quality care in the Trust.

Ignoring patients

There was no management culture of listening to patient concerns, and patient survey results consistently revealed dissatisfaction with the Trust. The complaints and serious untoward incidents processes were inadequate. The Trust board did not take on these matters in a robust manner and did not seem to be aware of the poor quality of care that was being delivered to patients.

Board governance

Despite the fact that a new chair and chief executive came on board in 2004 and 2005, the board failed to understand the full requirements and responsibilities of the statutory duty of clinical governance. The report describes the Trust’s clinical governance process as “vestigial”. Instead, the focus of the board was on financial issues.

Nursing levels

The shortage of nursing staff was placed low in order of priority compared to ensuring that the Trust retained financial viability by the board, as required by the Foundation Trust application process. Furthermore, there was no sense of urgency as to the seriousness of the staffing situation. There was poor leadership with regard to the issue as demonstrated by inadequate staffing policies, poor training, reduction in standards and a tolerance of a lower quality of patient care.

Nursing staff did report many instances of poor-quality care due to inadequate staffing levels but were not supported effectively by their management or their RCN representatives.

Scrutiny by patients and other agencies

Patients and their carers were excluded from involvement in improving the quality of care by the Trust. The local Patient and Public Forum and Local Involvement Network (LINk), both bodies designed to support patients, were ineffective as much of their energy was directed at procedures and internal discussions.

Local authority scrutiny committees did not understand the significance of the events occurring at the Trust and local MPs passed on the complaints to others for resolution without adequate follow-up.

The local GPs raised concerns only when the HCC announced that it was conducting a specific investigation into the issues raised by patients and carers.

The PCT was unable to carry out detailed monitoring of the Trust services as it was undergoing a reconfiguration of its commissioning arm during the period in question, and the SHA was focused on getting the Trust through the Foundation Trust process and did not report quality concerns to other agencies such as the DH or Monitor.


The recommendations covered 18 main areas:

  • implementation of the recommendations (ie everyone at all levels, including all staff within a Trust, commissioners, regulatory bodies and other NHS bodies) have a responsibility to ensure high-quality patient care and have due regard to the NHS Constitution

  • making patients a priority

  • essential standards of behaviour

  • a shared caring culture

  • effective standards of healthcare

  • regulation of healthcare by Monitor (the Foundation Trust regulator) and health and safety by the Health and Safety Executive

  • the role of supportive agencies such as the NHS Litigation Authority

  • handling of complaints

  • commissioning for standards of care

  • performance management within the NHS

  • scrutiny of the public and patients

  • education and training of doctors and nurses

  • openness, transparency and candour

  • leadership (Trust and DH)

  • fitness to practise plus regulation of healthcare professionals

  • care of older people

  • availability of information

  • coroners and inquests.

The lessons for primary care

Although the events at Mid Staffordshire NHS Foundation Trust took place within a hospital setting, there are profound effects on primary care in terms of commissioning as well as provision.

Clinical commissioning groups (CCGs)

The report identified the essential role of commissioners in ensuring that good working relationships are developed with providers in order to ensure that high standards of patient care are delivered. This can be reinforced through effective service specifications, which draw attention to standards and the Standard NHS Contract. These standards must be monitored closely and regularly by the CCGs so that quality issues, eg complaints, serious untoward incidents, etc can be picked up early and managed appropriately.

CCGs should pay particular attention to the duty of patient and public involvement in the commissioning and provision of healthcare and take seriously and investigate concerns raised by their local population. Individual GPs can support this by passing on feedback from their patients and families to the CCG.

CCGs can play a key role in ensuring that wider agencies are informed of any issues in which they are required to act. One of the main mechanisms can be through the local Health and Wellbeing Board as well as through the local area team of the NHS Commissioning Board.

There are still some Trusts going through the Foundation Trust “pipeline” for authorisation and CCGs, as well as their constituent GPs, have an important role in highlighting any quality concerns to Monitor.

The NHS Constitution

Patients should be the first priority in everything that is done by the NHS and the NHS Constitution should be revised to include references to required standards of behaviour by staff.

Organisations (this could include GP practices) will be required to demonstrate a “duty of candour”, ie explaining to a patient when a mistake is made or an omission occurs and offer support whether or not a patient has requested this.

Fitness to practise (healthcare assistants)

Up to now, Healthcare Assistants (HCAs) or healthcare support workers have had no consistent training, whether in primary or secondary care. The report recommends that HCAs have training based on national standards and have a national code of conduct and registration system.

HCAs play an important role in primary care and their training has been variable. This will be an area that not only CCGs and individual practices will need to improve on.

What happens next

The Government is currently considering the recommendations of the report and will publish its response in March 2013. Many of the recommendations are currently taking place but some of the key actions will need national action and legislation.

Whatever the outcome of the Government’s response, important lessons do need to be taken on board by the NHS as a whole and to remember that compassion must be the first consideration when delivering care.