looking back to the future: a personal reflection on the francis inquiry

The Francis Inquiry report wascompleted in 2013 after an

investigation over the precedingtwo years, focusing on presumedexcess deaths at Mid StaffordshireNHS Foundation Trust between2005 and 2009.1 It was reportedthat between 400–1200 excessdeaths occurred, mainly involvingpeople over the age of 70 years.

Following this finding, it was dis-covered that a further 10 NHS hos-pitals had similar rates of excessdeaths among similar age groups,although the subsequent KeoghReview2 cast doubts on the validityof the methodology used.Nevertheless, NHS England decidedto halt the use of the Liverpool CarePathway (LCP) to assist the deathsof older patients in hospital, since asignificant proportion of peoplewho died at Mid StaffordshireHospital were on this pathway.

All this occurred against thebackground of an NHS Englandtarget, backed up by extra pay-ment, of getting a higher propor-tion of patients dying in hospital onthe LCP.3 Furthermore, all the hos-pitals named as having excessdeaths had ongoing financialdeficits. These facts were not par-ticularly highlighted by Francis,who chose to concentrate on ‘inef-fectual’ leadership and a ‘bullying’culture where whistleblowers werepersecuted by management.

The Francis Inquiry hasresulted in the dismissal of somemanagers and senior nurses whowere working at Mid Staffordshire.

Despite 43 referrals of medical staffbeing made to the General MedicalCouncil (GMC), none of the doc-tors have undergone formal inves-tigation of practice. The statementfrom the GMC confirmed that thiswas on the basis of legal advice.4

Unanswered questionsThere has been no systematicinvestigation of the medical andnursing notes of the patientsplaced on the LCP in MidStaffordshire or in the other hos-pitals named by NHS England. Inparticular, the crucial issue ofpotential discrepancies betweenthe diagnoses described during thefinal inpatient stay and the causesof death in death certificates havenot been investigated. Researchinto this issue is urgently awaited.

From my standpoint as an OldAge Psychiatrist, the concern iswhether incapacitous older people,suffering from delirium, dementiaand depression, were inappropri-ately– and precipitously – placedon the LCP by the treating multi-disciplinary teams (MDTs). Thiswould have resulted in fluids, foodand active rehabilitation beingwithheld. These psychiatric condi-tions are, of course, treatable in theshort term and do not necessarilylead to death. It is questionable ifthe LCP should have been appliedunder these conditions in the firstplace, as it was designed for termi-nal cancer patients, where timing ofdeath is much more predictable.However, withholding fluid is more

predictable in causing death –through acute kidney injury andchest infections.

Biases pertinent to multidisciplinary teamsThere are three common biases thatcan influence an MDT. These havebeen described in a number of set-tings including health, banking andengineering. These are affective bias(‘heart ruling the head’), group-think (‘we are the greatest’) andescalation of commitment (‘throw-ing good money after bad’). It is myopinion that these biases could haveplayed a role in the teams con-cerned in the following ways.

Firstly, with regard to affectivebias,5 it is possible that the directionby NHS England of placing morepeople on the LCP (backed up byfinancial inducement) could pro-vide sufficient motivation to activelyseek out patients who could poten-tially die in hospital. There was anurgent need in these hospitals tobalance budgets, which would havedevolved to individual departmentsand wards. Further more, ‘clinicalexcellence awards’ are increasinglyassociated with ‘performance tar-gets’ defined by Trust management,which could provide motivation tomake certain decisions.

Considering groupthink,6 a ‘bul-lying’ culture within an MDT canlead to pressure to suppress dissenton overt or covert team objectives.Typically there is a ‘mind guard’within teams to keep dissent at bay.Individuals within the team (for rea-

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Looking back to the future: a personalreflection on the Francis InquiryPrasanna de Silva BMedBiol, MRCPsych

Following on from the Francis Inquiry, multidisciplinary teams need to reflect deeply onwhether biases have influenced their decision making in order to prevent similar mistakes in the future, argues Dr de Silva

sons of fear, or for potential personalgain) can decide not to express acontrary opinion, thereby confirm-ing the correctness of the MDTapproach. In MDTs where group-think is present, behaviours eitherto avoid or dismiss external criticismwill be employed to maintain groupconfidence and cohesion. Thismight, for example, include criti-cisms from patient’s relatives.

Finally, regarding escalation ofcommitment,7 some MDTs willfind it extremely difficult to acceptthat the current approach towardsa patient is leading to costly andpotentially catastrophic conse-quences. The explanation is thatmuch cost (and reputation) hasbeen invested already, making itdifficult to change direction. If theapproach taken with one patient isreversed, it leads to questions aboutmuch larger numbers of patients,which would cause major reputa-tional damage and potentially trig-ger an external review.

It is often difficult to verify biasoccurring in teams, although e-mailexchanges have been invaluable inascertaining this within the financialindustry. It is more helpful to beaware of biases that could affectMDTs and to reflect as teams on therole they play in day to day practice.Most clinicians in hospitals wouldsuggest they do not have the time tomeet as a MDT to discuss theseissues. However, reflective practiceis now a core component ofappraisals leading to relicensing, sodoctors do have the motivation tocarry out this work either individu-ally or as a team. Application of theLCP does involve medical consent;the ultimate decision, in my experi-ence, is made by medical staff.

Lessons from recent historyExcess deaths in hospitals and simi-lar institutions, either through neg-lect or design, is not unknownoversees. In Germany, during the

Weimar republic (1919-1933), finan-cial constraints resulted in the wellestablished community care pro-gramme being curtailed and vulner-able individuals – mainly olderpeople with mental health issues –being returned to institutions (theequivalent of our community hospi-tals). Coincidently, there were dis-cussions involving lawyers, doctorsand politicians about the economiccosts to the state of maintainingthese vulnerable individuals, result-ing in the phrase ‘a life not worth liv-ing’.8,9 Initially, this notion resultedin incremental neglect in institu-tions, involving reduced rations andmedical treatment, ultimately lead-ing to ‘mercy killings’ of peopleusing lethal injections. Medical staffled this process, and following theend of World War II, most of thesedoctors returned to their posts.

Clearly, this is not a path thatdoctors in the UK would conceiv-ably follow, considering due dili-gence provided by the GMC and thejudiciary. The actions at MidStaffordshire are more likely to bemisjudgements and errors of omis-sion, rather than errors of commis-sion. However, as studies by Milgramand colleagues have shown,10 appar-ently empathic individuals, givenenough direction by authority fig-ures, can resort to cruelty.

Ways forwardClearly, there are major methodolog-ical problems in identifying samplesof excess and avoidable deaths,although patients in hospitals placedon the LCP would be a good startingpoint, comparing people with andwithout cancer as the principal diag-nosis. Nursing notes would indicatethe degree of involvement of the var-ious disciplines in deciding place-ment of older people on the LCP,and also give an indication of otherproblems, including the existence ofdelirium, dementia and depression.Examination of primary care records

might help to ascertain any psychi-atric or other co-morbidity prior tothe final admissions. It would also beworthwhile determining the extentof involvement of relatives and othercarers in the case of avoidable deaths.

From a broader perspective, allprofessionals working in MDTs needto actively use reflective practice,and document the lessons learnt intheir appraisal documents. Theinfluence of biases described aboveis regularly discussed in non-healthsettings, including in the financialindustry post-2008, and I see no rea-son why medicine should not followsuit. Surely, evidence of reflection as part of a MDT should be a corecomponent of the evidence for medical practitioners applying forrelicensing.

I hope this article will generatefurther thinking, helping to ensuresafer and fairer management of vul-nerable individuals with multimor-bidity – increasingly the norm inmodern hospital care.

Declaration of interestsNone declared.

Dr de Silva is a Retired ConsultantOld Age Psychiatrist

References1. Francis, R. Report of the Mid Staffordshire NHSFoundation Trust Public Inquiry. London: The StationaryOffice, 2013.2. Keogh B. Review into the quality of care and treatmentprovided by 14 hospital trusts in England: overview report.NHS, 2013. www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/Overview.aspx3. Bingham J. NHS millions for controversial care path-way. The Telegraph 01/11/2012.4. Dickson N. GMC Mid Staffordshire Public Inquiry. GMC,2013. www.gmc-uk.org/news/14380.asp5. Finklestein S, Whitehead J, Campbell A, eds. AffectiveBias: Why good leaders make bad decisions. HarvardUniversity Press, 2009.6. Janis IL. Victims of Groupthink. Houghton Miffin,Boston, 1972.7. Staw BM. Escalation of commitment. AcadManagerial Rev 1981;6(4):577-84.8. Elkins D. Unworthy of Life. Athanatos PublishingGroup, 2013.9. Binding K, Hoche H. Allowing the Destruction of LifeUnworthy of Life: Its Measure and Form (Translation byModak C). Suzeteo Enterprises, 2012. www.lifeunworthy-oflife.com10. Milgram S. Behavioral study of obedience. J AbnormalSocial Psychol 1963;67(4):371-8.

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