The final report following the Mid Staffordshire NHS Foundation Trust Public Inquiry was published on 06.02.13. The Inquiry was carried out following a series of failures on the part of the Staffordshire Trust Board.
It concluded that the Trust did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to its attention. Above all, the Trust failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. The Trust focused on reaching national access targets, achieving financial balance and seeking foundation trust status at the cost of delivering acceptable standards of care.
Following the Inquiry, five other Hospital Trusts are to be investigated. The following Trusts have had persistently high death rates for two years:
– Colchester Hospital University NHS Foundation Trust,
– Tameside Hospital NHS Foundation Trust,
– Blackpool Teaching Hospitals NHS Foundation Trust,
– Basildon and Thurrock University Hospitals NHS Foundation Trust and
– East Lancashire Hospitals NHS Trust.
High death rates were one of the factors that triggered the original investigation into Stafford Hospital.
The report produced 290 recommendations aimed at “fundamental change” aiming to prevent the public losing confidence in the health service. These have been divided into 5 main areas:
- New “fundamental standards” of compliance, with clear means of enforcement
– If failings lead to death/serious harm to patients then legal sanctions are appropriate.
– NHS staff should be prosecuted if information about poor care is hidden. Further, staff should be open with patients if mistakes are made.
- Greater openness, transparency and candour
– There should be a criminal offence for any registered doctor, nurse or health professional to mislead regulators. They would also have an obligation of “candour” to patients or families and be trained in compassion.
- Improved support for compassionate, caring and committed nursing
– An increased focus on compassion in the recruitment, training and education of nurses, including an aptitude test for new recruits and regular checks of competence as is being rolled out for doctors.
- Accurate, useful and relevant information
- Better healthcare leadership
– Senior managers should given a code of conduct and it should be possible to disqualify them if they are not fit to hold such position.