Report of the Mid Staffordshire NHS FT Public Inquiry by Robert Francis, QC Andrew Geldard, Chief Executive

1. 27 February 2013 Report of the Mid Staffordshire NHS FT Public Inquiry by Robert Francis, QC Andrew Geldard, Chief Executive

2. Background 2007 – mortality rate concerns 2008 – HCC investigate trust reaction and number of complaints 2009 – HCC critical report – 18 recommendations 2008/09 – increasing outcry by patients/ relatives and a number of smaller reviews 2009 – first independent Inquiry by Francis commissioned into care between 2005-08, heard harrowing stories. Reported in Feb 2010 2010 - Monitor publish ‘The role of boards in improving safety’ 2010 – Public Inquiry commissioned from Francis, building on first, examining culture, systems of commissioning, supervisory and regulatory organisations and other agencies

3. Robert Francis Press Conference Statement (06.02.2013) • “We need a patient centred culture, no tolerance of non compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership and caring, compassionate nursing, and useful and accurate information about services” • “The Trust Board was weak. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. It did not tackle the tolerance of poor standards and the disengagement of senior clinical staff from managerial and leadership responsibilities. These failures were in part due to a focus on reaching targets, achieving financial balance and seeking foundation trust status at the cost of delivering acceptable standards of care” • “Conventionally, some might say depressingly, when a disaster has occurred in the NHS the usual approach has been to blame and sack individuals or propose major reorganisations. What has been found to be wrong here cannot be cured by finding scapegoats, and/or recommending major reorganisation yet again”

4. Key findings • Apalling suffering of many patients, failure of care and compassion, warning signs ignored • Serious failure of the Trust Board, ignored patient voices, focused on targets and finances • Systems of checks and balances failed patients, failure of regulators (including commissioners) • In total 290 recommendations along 5 themes “ I suggest that the Board of any Trust could reflect on their own work in the light of what is described in my report” Robert Francis, QC

5. Structure of Fundamental Standards and measures of Compliance • NHS Constitution strengthened: patients first • Development of clear fundamental standards of behaviour, safety and quality • NICE guidance to cover staff mix and cultural outcomes • CQC as single regulator, transfer of FT authorisation process • Chief Inspector of Hospitals • Explicit judgements about culture of organisation • Strengthen inspection regime – assuring clean, safe and caring • Criminal offence to mislead Regulator • Clear focus on role of commissioners to drive up standards • Poor Friends & Family scores – immediate inspection • Immediate inspections announced at 14 hospitals – mortality rates

6. How staffing level standards could be determined and enforced: NICE NHS Constitution Standards NHS Litigation Authority Single regulator Providers & Commissioners “The procedures and metrics produced by NICE should include evidence-based tools for establishing the staffing needs of each service. These measures need to be readily understood and accepted by the public and healthcare professionals”

7. Openness, transparency and candour • Culture of openness / statutory duty of truthfulness where cause harm • Criminal offence to withhold information where harm, or to mislead • Improved complaints handling • Strengthening support for governors, and role of governors and NEDs • Consistent structure for local Healthwatch

8. Improved support to assure compassionate, caring and committed staff • Selection and promotion on basis of compassion • Creation of training standards to deliver consistent and compassionate care • Strengthened role of professional bodies as voice for profession • Healthcare workers regulated by a registration scheme • Patients allocated a key nurse, ward leaders not office based

9. Stronger healthcare leadership • Registration scheme for NHS Directors, and requirements on FTs to train adequately • NHS Leadership College • Tougher role for professional regulators • Health Education England and Local Education & Training Boards to have strengthened medical inputs

10. Accurate, useful and relevant information “The lifeblood of an open, transparent and candid culture” • Improvements in core information systems to improve safety and effectiveness of treatments, as well as for statistical purposes • Publication of more sophisticated measurements of effectiveness of treatments / interventions • Transparency about performance and outcomes to all • Boards must be accountable for presentation to the public of balanced and candid information about compliance with fundamental standards

11. Government’s initial commitment to move quickly on: Putting Patients First • Single failure regime • Poor Friends & Family test inspections • Review into making ‘Zero Harm’ a reality • Compassion as basis of nurse selection /?pay link to quality Accountability & Transparency • NMC and GMC to explain inactions and Law Commission to advise on strengthening NMC decision making processes • Consider moving criminal prosecutions from H&SE to CQC Regulatory actions • CQC new Chief Inspector of Hospitals by Autumn 2013 • Inspection regime revisited – clean, safe and caring focus • Immediate investigation of 14 highest mortality rate hospitals • Review of complaints handling (includes Ann Clwyd, MP)

12. Discussion and Next Steps