The Francis Report (Report of the Mid- Staffordshire NHS Foundation Trust public inquiry) and the Government s response

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1 The Francis Reprt (Reprt f the Mid- Staffrdshire NHS Fundatin Trust public inquiry) and the Gvernment s respnse Standard Nte: SN/SP/6690 Last updated: 2 December 2013 Authr: Sectin Thmas Pwell Scial Plicy On 6 February 2013 the reprt f the Mid Staffrdshire NHS Fundatin Trust Public Inquiry, led by Rbert Francis QC, was published. This public inquiry fllwed a number f earlier inquiries and was specifically established t examine why serius failures in care at Mid- Staffrdshire NHS Fundatin Trust befre 2009 were nt acted n sner by the varius respnsible rganisatins. The Francis Reprt made 290 recmmendatins designed t create a cmmn patient centred culture acrss the NHS. Key themes included the need fr clear fundamental standards and measures f cmpliance, and greater penness, transparency and candur thrughut the system, underpinned by statute where necessary. This briefing prvides backgrund t the public inquiry led by Rbert Francis QC, and ther preceding reviews. It als prvides sme infrmatin n the Gvernment s initial respnse t the Francis reprt, which was published n 6 February The Gvernment detailed respnse t each f the 290 recmmendatins, Hard Truths, the Jurney t Putting Patients First, was published n 19 Nvember The Gvernment fully r partially accepts all but nine f the Francis recmmendatins. Sme f the measures set ut in Part 2 f the Care Bill are in respnse t specific recmmendatins abut transparency and the regulatin f care standards in the Francis Reprt and further infrmatin abut these can be fund in the Library Standard Nte, Lrds stages f the Care Bill: Health prvisins (SN06769). Tw further Library standard ntes refer t the public inquiry, and specific plicies annunced in respnse t the earlier inquiries, NHS whistleblwing prcedures in England (SN06490) and NHS cmplaints prcedures in England (SN05401). This infrmatin is prvided t Members f Parliament in supprt f their parliamentary duties and is nt intended t address the specific circumstances f any particular individual. It shuld nt be relied upn as being up t date; the law r plicies may have changed since it was last updated; and it shuld nt be relied upn as legal r prfessinal advice r as a substitute fr it. A suitably qualified prfessinal shuld be cnsulted if specific advice r infrmatin is required. This infrmatin is prvided subject t ur general terms and cnditins which are available nline r may be prvided n request in hard cpy. Authrs are available t discuss the cntent f this briefing with Members and their staff, but nt with the general public.

2 Cntents 1 Initial reprts int care at Staffrd Hspital and the First Francis inquiry The first Francis inquiry and the previus Gvernment s respnse 2 2 The Public Inquiry and the current Gvernment s respnse Backgrund Reprt f the Public Inquiry The Prime Minister s respnse Patients First and Fremst 9 1 Initial reprts int care at Staffrd Hspital and the First Francis inquiry In 2008 the then healthcare regulatr, the Healthcare Cmmissin, launched a review int standards f care at Staffrd Hspital, part f the Mid-Staffrdshire NHS Fundatin Trust, prmpted by cncerns abut the Trust s high hspital standardised mrtality rati, and in respnse t cmplaints frm patients and their relatives. In March 2009 the Healthcare Cmmissin published its reprt, which revealed serius failures in care ver the perid frm 2005 t As well as immediate steps t try and imprve patient safety, care standards and public cnfidence, including the appintment f a new chair and chief executive in July 2009 and a prgramme f regular inspectins by the Care Quality Cmmissin, the Gvernment set up a review led by Dr Clin Thmé 1 and an independent inquiry led by Rbert Francis QC. 2 These reprts fund widespread and systemic deficiencies in care at the Trust, including a lack f effective gvernance arrangements. The Fundatin Trust and the key prfessinal regulatry bdies, the General Medical Cuncil and the Nursing and Midwifery Cuncil, have als investigated a number f clinical staff ptentially implicated by events at Staffrd Hspital The first Francis inquiry and the previus Gvernment s respnse In July 2009 the Secretary f State fr Health under the previus Gvernment, Andy Burnham, cmmissined Rbert Francis QC t cnduct an independent inquiry in t what went wrng at Staffrd hspital and why; what lessns culd be learned; and what further actin was needed t ensure the trust was delivering a sustainably gd service t its lcal ppulatin. The inquiry fund evidence f an rganisatin with a culture "nt cnducive t prviding gd care fr patients r a supprtive wrking envirnment fr staff". The bard did nt cnsider patient cmplaints, clinical gvernance r quality at its meetings. Meetings were held in private, and the reprt describes the bard as having "lst sight f its fundamental respnsibility t prvide safe care." That dysfunctinality extended t the way targets were Mid Staffrdshire NHS Fundatin Trust: A review f lessns learnt fr cmmissiners and perfrmance managers fllwing the Healthcare Cmmissin investigatin, (Dr David Clin Thmé), 29 April 2009 The Independent Inquiry int care prvided by Mid Staffrdshire NHS Fundatin Trust, (chaired by Rbert Francis QC), 24 February Staffrd-Hspital-scandal.html 2

3 managed in the trust and the failure t put in place adequate staffing levels t prvide safe patient care. The management f the trust cut staffing t dangerusly lw levels, at ne pint leaving A and E with a third fewer nurses than were needed t prvide safe care. Amng staff the reprt fund failures f prfessinal standards and clinical leadership. In ttal, Rbert Francis made 18 recmmendatins, mst relating t the Trust with sme applying the NHS mre generally, r t the Department f Health. Recmmendatins included that the Trust must make its visible first pririty the delivery f a high-class standard f care t all its patients by putting their needs first. It shuld nt prvide a service in areas where it cannt achieve such a standard. The reprt recmmended that the NHS and Department review arrangements fr the training, appintment, supprt and accuntability f executive and nn-executive directrs f NHS trusts and NHS fundatin trusts. It als recmmended that the Department shuld set up a wrking grup t review the use f cmparative hspital mrtality statistics: In view f the uncertainties surrunding the use f cmparative mrtality statistics in assessing hspital perfrmance and the understanding f the term excess deaths, an independent wrking grup shuld be set up by the Department f Health t examine and reprt n the methdlgies in use. It shuld make recmmendatins as t hw such mrtality statistics shuld be cllected, analysed and published, bth t prmte public cnfidence and understanding f the prcess, and t assist hspitals t use such statistics as a prmpt t examine particular areas f patient care. Finally the first Francis reprt recmmended that the Gvernment shuld cnsider instigating an independent examinatin f the peratin f cmmissining, supervisry and regulatry bdies in relatin t their mnitring rle at Staffrd hspital with the bjective f learning lessns abut hw failing hspitals are identified. In his respnse t the Francis Inquiry in February 2010 Andy Burnham said the Gvernment accepted all the recmmendatins in full. Turning t the fur recmmendatins that applied t his Department, the Health Secretary annunced he wuld cnsult n a new system f prfessinal accreditatin fr senir NHS managers; imprve early warning systems in the NHS; update whistleblwing guidance; and place a greater fcus in the NHS n measuring patient satisfactin and staff satisfactin. Sme key sectins f his respnse are set ut in full:... Rbert Francis asks me t review hw cmparative mrtality statistics are cmpiled, as well as the methdlgies that underpin them, t imprve public cnfidence in and understanding f them. One f the principal reasns why the Healthcare Cmmissin launched its review in 2008 was that it was nt satisfied with the trust's explanatin f its high hspital standardised mrtality rati. The inquiry has cnsulted a range f experts n the issue, and Rbert Francis cncludes: "it is in my view misleading and a ptential misuse f the figures t extraplate frm them a cnclusin that any particular number r range f numbers f deaths were caused r cntributed t by inadequate care". Hwever, as he pints ut, there is n shared methdlgy fr HSMRs, nr any clear accunt f hw they shuld be used and interpreted. The result is cnfusin fr patients and the public. I therefre welcme and accept the recmmendatin t establish an independent wrking grup t examine and reprt n the methdlgies in use. The NHS medical directr, Prfessr Sir Bruce Kegh, has already established that grup, which includes the key parties invlved in develping and using HSMRs, as 3

4 well as leading academics and thers. The grup has cmmitted t develping a single HSMR fr the NHS.... the reprt calls fr a further independent examinatin f all the cmmissining, supervisry and regulatry bdies, in relatin t their mnitring rle at Staffrd, with the bjective f learning lessns abut hw failing hspitals are identified. I accept that recmmendatin, and can tell the Huse that Rbert Francis has agreed t chair the further inquiry. We are publishing draft terms f reference tday, and we welcme views n them. 4 2 The Public Inquiry and the current Gvernment s respnse 2.1 Backgrund On 9 June 2010 the new Secretary f State fr Health, Andrew Lansley, annunced that Rbert Francis had agreed t chair a secnd inquiry, which unlike the first wuld be held in public. In additin t being held in public, this inquiry had statutry pwers t cmpel witnesses t attend and speak under ath under the Inquiries Act It was expected that Rbert Francis wuld submit his reprt t the Secretary f State n 15 Octber 2012 but this was pushed back t 5 February 2013, with publicatin t take place the fllwing day. 5 Unlike the previus inquiries, which fcussed n failings within the Trust, the public inquiry lked at the peratin f the cmmissining, supervisry and regulatry bdies respnsible fr the Trust. In his statement t the Huse, the Secretary f State explained the ratinale fr the new inquiry: This was a failure f the trust first and fremst, but it was als a natinal failure f the regulatry and supervisry system, which shuld have secured the quality and safety f patient care. (...) Why did the primary care trust and strategic health authrity nt see what was happening and intervene earlier? Hw was the trust able t gain fundatin status while clinical standards were s pr? Why did the regulatry bdies nt act sner t investigate a trust whse mrtality rates had been significantly higher than the average since 2003 and whse recrd in dealing with serius cmplaints was s pr? The public deserve answers. 6 The Shadw Secretary f State, Andy Burnham, gave an assurance that the new inquiry wuld have the Oppsitin's full c-peratin. He als highlighted that he had signalled the need fr a secnd stage inquiry befre the General Electin, t lk int the actins f the supervisry and regulatry bdies Reprt f the Public Inquiry The Reprt f the Mid Staffrdshire NHS Fundatin Trust Public Inquiry, was published n 6 February 2013 and included 290 recmmendatins. 8 This was accmpanied by a statement t the Huse by the Prime Minister which set ut actins already taken and a cmmitment that the Gvernment wuld respnd in detail next mnth. 9 The Gvernment Statement by the Secretary f State fr Health, Andy Burnham, HC Deb 24 February 2010 c Further infrmatin abut the public inquiry is available here: HC Deb 9 June 2010, c333 Ibid. c335 Further infrmatin abut the public inquiry is available here: HC Deb 6 February 2013 c281 4

5 published mre detail in its initial published respnse, Patients First and Fremst, n 26 March A press release issued by the public inquiry nted that the inquiry had fund a stry f terrible and unnecessary suffering f hundreds f peple wh were failed by a system which ignred the warning signs f pr care and put crprate self interest and cst cntrl ahead f patients and their safety. The final reprt the inquiry made 290 recmmendatins designed t change this culture and make sure patients cme first by creating a cmmn patient centred culture acrss the NHS. 11 The press release highlighted sme f the reprt s key recmmendatins: A structure f fundamental standards and measures f cmpliance: A list f clear fundamental standards, which any patient is entitled t expect which identify the basic standards f care which shuld be in place t permit any hspital service t cntinue. These standards shuld be defined in genuine partnership with patients, the public and healthcare prfessinals and enshrined as duties, which healthcare prviders must cmply with. Nn cmpliance shuld nt be tlerated and any rganisatin nt able t cnsistently cmply shuld be prevented frm cntinuing a service which expses a patient t risk T cause death r serius harm t a patient by nn cmpliance withut reasnable excuse f the fundamental standards, shuld be a criminal ffence. Standard prcedures and guidance t enable rganisatin and individuals t cmply with these fundamental standards shuld be prduced by the Natinal Institute fr Clinical Excellence with the help f prfessinal and patient rganisatins. These fundamental standards shuld be pliced by the Care Quality Cmmissin (CQC) Openness, transparency and candur thrughut the system underpinned by statute. Withut this a cmmn culture f being pen and hnest with patients and regulatrs will nt spread. Including: A statutry duty t be truthful t patients where harm has r may have been caused Staff t be bliged by statute t make their emplyers aware f incidents in which harm has been r may have been caused t a patient Trusts have t be pen and hnest in their quality accunts describing their faults as well as their successes Patients First and Fremst: the Initial Gvernment Respnse t the Reprt f the Mid Staffrdshire NHS Fundatin Trust Public Inquiry (26 March 2013). The Mid Staffrdshire NHS Fundatin Trust Public Inquiry, Publicatin f the final reprt f the Mid Staffrdshire NHS Fundatin Trust Public Inquiry, press release, 6 February 2013, p1 5

6 The deliberate bstructin f the perfrmance f these duties and the deliberate deceptin f patients and the public shuld be a criminal ffence It shuld be a criminal ffence fr the directrs f Trusts t give deliberately misleading infrmatin t the public and the regulatrs The CQC shuld be respnsible fr plicing these bligatins Imprved supprt fr cmpassinate, caring and cmmitted nursing Entrants t the nursing prfessin shuld be assessed fr their aptitude t deliver and lead prper care, and their ability t cmmit themselves t the welfare f patients Training standards need t be created t ensure that qualified nurses are cmpetent t deliver cmpassinate care t a cnsistent standard Nurses need a strnger vice, including representatin in rganisatinal leadership and the encuragement f nursing leadership at ward level Healthcare wrkers shuld be regulated by a registratin scheme, preventing thse wh shuld nt be entrusted with the care f patients frm being emplyed t d s. Strnger healthcare leadership The establishment f an NHS leadership cllege, ffering all ptential and current leaders the chance t share in a cmmn frm f training t exemplify and implement a cmmn culture, cde f ethics and cnduct It shuld be pssible t disqualify thse guilty f serius breaches f the cde f cnduct r therwise fund unfit frm eligibility fr leadership psts A registratin scheme and a requirement need t be established that nly fit and prper persns are eligible t be directrs f NHS rganisatins. 12 Cmmenting n his recmmendatins Rbert Francis said: The NHS can prvide great care and the system and the peple in it shuld make sure that happens everywhere. The recmmendatins I am making tday represent nt the end but the beginning f a jurney twards a healthier culture in the NHS where patients are the first and fremst cnsideratin f the system and all thse wh wrk in it. It is the individual duty f every rganisatin and individual within the service t read this reprt and begin wrking n its recmmendatins tday. 13 The website fr the public inquiry is available at: The final reprt and assciated dcuments can be fund at: As abve, pp1 3 As abve, p3 6

7 2.3 The Prime Minister s respnse Fllwing the publicatin f the reprt, the Prime Minister made a statement t the Huse, which highlighted hw the different layers f NHS management had failed t address the failings at Mid-Staffs NHS Fundatin Trust: The inquiry finds that the appalling suffering at the Mid Staffrdshire hspital was primarily caused by a serius failure n the part f the trust bard, which failed t listen t patients and staff and failed t tackle what Rbert Francis calls an insidius negative culture invlving a tlerance f pr standards and a disengagement frm managerial and leadership respnsibilities. The inquiry finds, hwever, that the failure went far wider. The primary care trust assumed thers were taking respnsibility and s made little attempt t cllect prper infrmatin n the quality f care. The strategic health authrity was far t remte frm the patients it was there t serve, and it failed t be sufficiently sensitive t signs that patients might be at risk. Regulatrs, including Mnitr and the then Healthcare Cmmissin, failed t prtect patients frm substandard care. T many dctrs kept their heads dwn instead f speaking ut when things were wrng. The Ryal Cllege f Nursing was ineffective bth as a prfessinal representative rganisatin and as a trade unin and the Department f Health was t remte frm the reality f the services that it versees. 14 The Prime Minister cautined that the way Rbert Francis chrnicles the evidence f systemic failure means that we cannt say with cnfidence that failings f care are limited t ne hspital. 15 The Prime Minister aplgised fr the failing at the Fundatin Trust, and nted that actin had been, including the establishment f a Natinal Quality Bard and the quality accunts system under the previus Gvernment, and that his Gvernment have:...put cmpassin ahead f prcess-driven bureaucratic targets...put quality f care n a par with quality f treatment and set this ut explicitly in the mandate t the NHS Cmmissining Bard, tgether with a new visin fr cmpassinate nursing ;...intrduced a tugh new prgramme fr tracking and eliminating falls, pressure sres and hspital infectins ; and...demanded nursing runds, every hur, in every ward f every hspital. 16 He cncluded, hwever, that it is clear that we need t d mre, and said that the Gvernment will study every ne f the 290 recmmendatins in tday s reprt and... respnd in detail next mnth. 17 He added that immediate prgress was needed in three cre areas patient care, accuntability and defeating cmplacency : Patient Care HC Deb 6 February 2013 cc HC Deb 6 February 2013 c280 HC Deb 6 February 2013 cc HC Deb 6 February 2013 c281 7

8 Explaining hw patient care wuld be put ahead f finances, the Prime Minister nted that tday, when a hspital fails financially, its chair can be dismissed and the bard can be suspended, but failures in care rarely carry such cnsequences. He cntinued that is nt right, s we will create a single failure regime, where the suspensin f the bard can be triggered by failures in care as well as failures in finance, and we will put the vice f patients and staff at the heart f the way in which hspitals g abut their wrk. This wuld mean that where a significant prprtin f patients r staff raise serius cncerns abut what is happening in a hspital, immediate inspectin will result and suspensin f the hspital bard may well fllw. The Prime Minister cnfirmed plans t intrduce a friends and family test fr NHS services, and said that frm this year every patient, carer and member f staff wuld be given the pprtunity t say whether they wuld recmmend their hspital. He said that survey results wuld be published and that where a significant prprtin f patients r staff raise serius cncerns... immediate inspectin will result and suspensin f the hspital bard may well fllw. He said he had asked Dn Berwick, previusly a health plicy advisr t the President f the United States, t embed the cncept f zer harm within the NHS. 18 Addressing sme f the reprt s recmmendatins n nursing and healthcare assistants the Prime Minister said that nurses shuld be hired and prmted n the basis f having cmpassin as a vcatin, nt just academic qualificatins. Accuntability and transparency On accuntability and transparency, the Prime Minister nted that the first Francis reprt set ut very clearly what happened within Staffrd hspital, and it shuld have led t thse respnsible being brught t bk by the bard, by the regulatrs, by the prfessinal bdies and by the curts. But that did nt happen, adding that the system failed. He said the Nursing and Midwifery Cuncil and the General Medical Cuncil need t explain why, s far, n ne has been struck ff, and nted that they had been invited by the Secretary f State fr Health t explain what steps they will take t strengthen their systems f accuntability in the light f this reprt. He said the Gvernment wuld ask the Law Cmmissin t advise n sweeping away the Nursing and Midwifery Cuncil s utdated and inflexible decisin-making prcesses. He said that the Health and Safety Executive als needs t explain its decisins nt t prsecute in specific cases, adding that the Gvernment wuld lk clsely at his recmmendatin t transfer the right t cnduct criminal prsecutins away frm the HSE t the Care Quality Cmmissin. Culture f cmplacency 18 HC Deb 6 February 2013 c281 8

9 the Prime Minister said we must purge the culture f cmplacency that is undermining the quality f care in ur cuntry, adding we need a hspital inspectins regime that des nt just lk at numerical targets but examines the quality f care and makes an pen, public and explicit judgment. The Prime Minister said he had asked the Care Quality Cmmissin t create a new pst, a chief inspectr f hspitals in rder t take persnal respnsibility fr that task with the new regime beginning in autumn In the meantime, the Prime Minister said he had asked the NHS medical directr, Prfessr Sir Bruce Kegh, t cnduct an immediate investigatin int the care at hspitals with the highest mrtality rates and t check that urgent remedial actin is being taken. In additin, he had asked Ann Clwyd MP and the chief executive f Suth Tees Hspitals NHS Fundatin Trust, Tricia Hart, t advise n hw NHS hspitals can handle cmplaints better in the future Patients First and Fremst Detail n the Gvernment s respnse can be fund in Patients First and Fremst: the Initial Gvernment Respnse t the Reprt f the Mid Staffrdshire NHS Fundatin Trust Public Inquiry (26 March 2013). This set ut a five pint plan t imprve the care that peple receive frm the NHS: Preventing and detecting prblems The sectins n preventing and detecting prblems prvided further infrmatin n prpsals fr a Chief Inspectr f Hspitals and it was subsequently annunced that Prfessr Sir Mike Richards had been appinted t this pst. He will lead a natinal team f hspital inspectrs that will carry ut targeted inspectins in respnse t quality cncerns and reginal teams f inspectrs wh will undertake rutine inspectins n a regular basis f all hspitals. He will als lead the develpment f a ratings system fr NHS acute hspitals and mental health trusts. It als nted plans t publish infrmatin n surgical utcmes, t intrduce penalties fr disinfrmatin, a statutry duty f candur and a ban n cntractual clauses that seek t prevent NHS staff whistleblwing. Taking actin prmptly This sectin included further detail f plans fr a failure regime, in which a Trust r Fundatin Trust Bard culd be suspended and the hspital put int administratin if it fails t meet fundamental standards f care. Ensuring rbust accuntability This sectin stated that as part f the Law Cmmissin s review f the legislatin that applies t the prfessinal regulatrs, the Gvernment wuld seek t legislate at the earliest pprtunity t cnslidate measures int a single Act that wuld enable faster and mre practive actin n individual prfessinal failings. This sectin als utlined prpsals fr a barring scheme fr failed NHS managers. Ensuring staff are trained and mtivated This sectin set ut plans fr student nurses t serve up t a year as a healthcare assistant first, t prmte frntline caring experience and values, and t intrduce a revalidatin 19 HC Deb 6 February 2013 cc

10 scheme fr nurses. It als set ut prpsals fr minimum training standards and a barring scheme fr healthcare assistants. 10