+

The report of the Mid Staffs

Public Inquiry

Dr Rosie Belcher

ST6 St Mary’s Hospital

16.3.13

+Content

Background: the situation at Mid Staffs

Report of the Independent Inquiry (“Francis 1”)

Report of the Public Inquiry (“Francis 2”)

This is a look at the Francis report and it’s potential implications for individual doctors and jobbing geriatricians. I’ve also looked in particular at his recommendations for medical education and training. It is not a comprehensive summary! I’ve skipped a lot of stuff about standards as this is of less immediate relevance.

I have indicated Recommendations from Francis like this. Numbers in brackets refer to the number of the recommendation in the report (in case you want to check up). There are 290 recommendations in total.

+Mid Staffordshire Foundation Trust

Concerns about lack of clinical governance, low staff levels and poor standards at the Trust had existed for some time (at least prior to 2004)

Trying to become a Foundation Trust 2005-2008

2007 Concerns raised about mortality rates (SHMR)

Although there has been interesting debates about these since – see http://www.bmj.com/content/346/bmj.f562, and the linked editorial, and responses from others.

April 2008 Healthcare Commission (HCC) launched investigation, NOT as a result of the actual mortality stats, but due to concern about:

The Trust’s reaction to the mortality stats

The Trust’s reaction to complaints

+Healthcare Commission report

Healthcare Commission (HCC) reported in March 2009 on failings in emergency care.

Triggered

Review of hospital’s procedures for emergency admissions and treatment

Investigation of how commissioning and performance management systems missed what was

happening in the department

But there were focused on A&E. There was growing pressure from the public, particularly a

local group (Cure the NHS, set up by a relative of someone who had died at Mid Staffs) to

look at other departments, and to do this through a Public Inquiry.

July 2009 Andy Burnham conceded and set up an Independent Inquiry and Robert Francis

QC.

Reported Feb 2010 on:

Individual patient cases and internal operations of the Trust

Identify further lessons to be learned

Suggest additional action to be taken to ensure good care

+Independent Inquiry (“Francis 1”)

Lack of basic care across numerous wards and departments

Culture at the Trust was not helpful

Fear of adverse consequences for reporting problems

Low morale

High priority placed on achievement of (financial) targets and acceptance of poor standards

Consultant body was dissociated from management

Management dominated by financial targets and achieving Foundation status

No effective clinical governance, and a failure to recognize or attempt to correct this

Statistics and data were preferred to patient experience data, focus on systems not outcomes

Where problems were recognized, there was a lack of urgency in solving them.

+Independent Inquiry (“Francis 1”):

recommendations

The Trust should make visible it’s first priority to deliver a high standard of care and should

develop links with other organizations to help it do this

The Trust, the Royal Colleges, the deanery and the school of nursing should review their

training programmes

Improve audit and clinical governance processes

Foster a culture of openness, including openness to staff members who raise concerns

about care

Sec State for Health and Monitor should review the appointment and accountability of

directors of NHS Trusts, with a view to creating professional standards overseen by an

independent body

Consider an “independent examination of the operation of commissioning, supervisory and

regulatory bodies in relation to their monitoring role at Stafford hospital with the objective of

learning lessons about how failing hospitals are identified”

i.e. Francis was recommending a further, more wide-ranging inquiry in to why it took so

long for the bodies that were supposed to regulating the hospital to notice

+Public Inquiry (“Francis 2”)

So a Public Inquiry, under the Inquiries Act 2005 was set up to do this.

Public Inquiries can

Compel individuals to give evidence

Command documentary evidence (eg can demand to see internal Trust communication, minutes of meetings etc)

They are held in public (obviously!). Francis held most hearings in Stafford, to give locally affected people the opportunity to attend.

Commissioned to examine:

Commissioning, supervisory and regulatory organizations in relation to their monitoring role at Mid Staffs

Why serious problems at the Trust were not identified or acted on sooner

Identify lessons to be drawn

Make recommendations to the Secretary of State for Health

Reported Feb 6th 2013

+Public Inquiry: themes

Certain themes keep recurring in the report

Culture of the Trust

Need for more information sharing/co-working between organizations with different but overlapping interests/responsibilities

Constant structural change, with consequent loss of expertise/information

Makes lots of recommendations, on a wide range of topics.

Following slides are a summary of some sections of the report, with the relevant recommendations

+Public Inquiry: Introduction 1

Received numerous requests to examine failures of systems in other Trusts and services

“Stafford was not an event of such rarity or improbability that it would be safe to assume that it has not

been and will not be repeated” (para 76)

Francis does not go so far as to say that he thinks there are definitely other instances of care as poor

as at Mid Staffs, but implies this is likely to be the case

Notes that the Health and Social Care Act 2012 was passed during the Inquiry

Structural changes in the NHS

Numerous bodies investigated to longer exist in their previous form (eg HCC CQC)

“This report should not be understood as intending to offer a comprehensive and up to the minute

account of the current position” (para 37)

There is a sense of frustration in the report that the ground was shifting underneath him and in some

ways the report was already out of date by the time it was published

Recommendation: “Before a proposal for any major structural change to the healthcare system is

accepted, an impact and risk assessment should be undertaken by the DH and should be debated

publicly.” (286)

Recommendation: Future transitions should be managed in reasonable timescales, maintaining

corporate memory, and information and documentation (286)

+Public Inquiry: Introduction 2

Previous inquiries have resulted in a lack of accountability for

implementing changes

Recommendation: All healthcare organizations should consider how

the findings and recommendations of the report should be applied to

them, and announce publically how they are going to respond (1)

Recommendation: Healthcare organizations should then publish at

least annually information about their actions on the

recommendations (1)

Recommendation: DH should collate this information (1)

I cannot find any responses on local Trust websites, including

Imperial.

+Public Inquiry: “Warning signs”

Negative culture

Tolerance of poor standards

Isolation from practice elsewhere

Denial when concerns were raised

Culture of self promotion rather than critical analysis

Patients not heard

Procedures for dealing with complaints and SUIs were inadequate

Staff and patient surveys showed dissatisfaction, but were ignored

Managers and regulators consistently said they had no idea about the problems throughout both inquiries

Francis dismisses this and gives a number of warning signs which should have been heeded:

Professional disengagement

Especially senior consultants

Poor governance

Clinical governance systems were “vestigial”

Focus on finances not standards of care

Inadequate risk assessment of staff reduction

+Culture

Francis comments repeatedly on the culture at the Trust, where staff generally had low morale and were disengaged from management processes. The culture tolerated poor standards and discouraged staff from raising their concerns

Francis suggests there needs to be more openness, transparency and candour

Recommendation: “Gagging” clauses should not be permitted (179)

Recommendation: A statutory duty of candour by healthcare workers towards individual patients when there has been an error (174, 181)

Recommendation: A statutory duty of candour by healthcare organisations towards regulatory and commissioning bodies (176, 182)

Including a criminal offence for any registered healthcare professional, manager or director to make an untruthful statement to a regulator, or obstruct the performance of a regulator’s duties (183)

+GPs

Local GPs only expressed concerns after the HCC

investigation was announced

Were they unaware, or aware and apathetic?

Francis thinks GPs should monitor the care their patients get

from other local providers

Recommendation: GPs “should have an obligation to their patients

to keep themselves informed of the standard of service available

from providers” and make any concerns known to the CQC and

relevant commissioner (123)

Unclear if this is a collective or individual responsibility

+Monitor

Determines whether Trusts can become Foundation trusts and ensures that Foundation Trusts comply with their conditions

Is the Trust well governed?

Is the Trust financially viable?

Is the Trust legally constituted?

Francis comments that there was a failure of the application process as it did not identify the problems at Mid Staffs

Monitor’s focus was on finance and corporate governance

Monitor relied on the Trust’s assurances on clinical issues, and did not probe

Monitor did not talk to the HCC

+Healthcare Commission

Aim was to promote and drive improvement in quality of healthcare

Statutory duty to assess the provision and quality of healthcare and review the performance of all NHS Trusts

Report criticises standards for being formulated by the DH with little clinician input or buy-in. Standards are also mixture of very general and v specific.

Reliance on self assessment and presence of systems, rather than actual achievements and outcomes

Statements by the Trust were accepted at face value without challenge

Thoroughness of the eventual investigation is praised however

+Care Quality Commission

Report comments that has clearly faced a number of

challenges but seems to have planned activities to fit the

resources available, rather than the job it is commissioned to

do.

Report characterizes it as a defensive organization, which did

not respond to concerns about itself constructively

Report makes a large number of recommendations about these

organizations (or their successors) and in particular about the

standards that they use.

+Information

There was a lack of information sharing between all organizations.

Recommendation: All healthcare providers should publish information on the performance of their consultants and specialist teams (262)

Morbidity

Mortality

Outcomes

Patient satisfaction

Recommendation: Health and Social Care Information Centre for collection analysis and publication of healthcare information (257)

To include some of the functions of the National Patient Safety Agency

Recommendation: Electronic patient records, with the facility for patients to read and comment on them (244)

+GMC and NMC

Three doctors are facing fitness to practice hearings

All had significant managerial responsibilities as MD/deputy MD

GMC and NMC are criticized for dealing with cases individually only

Recommendation: Should have a policy covering generic complaints were no individuals or multiple individuals are named (222)

Recommendation: Should be more proactive in investigating based on monitoring fitness to practice, not just complaints (222)

Recommendation: Should liaise more closely with each other and the CQC (234)

Recommendation: Suggests there should be an independent tribunal to deal with issues involving professionals from more than one field (235)

+Medical Education and Training 1

No concerns about the Trust were raised through those with oversight of training of healthcare professionals

Concerns about bullying/abuse of students and trainees were not followed up

Recommendation: Medical schools should actively seek feedback from students about the quality of care on their placements (158)

Recommendation: Medical students and trainees should be surveyed about their perceptions of the standards of care in their placements (159)

This is started in 2012 in the new GMC survey for trainees. 5% of trainees suggested they had concerns about care in their workplace. See www.gmc-uk.org/NTS_2012_response_to_concerns_summary.pdf_50237792.pdf

+Medical education and training 2

PMETB/GMC/Deaneries did not consider patient safety

standards as relevant to them

There is little communication between patient safety/clinical

standards organizations and medical education organizations.

Recommendation: Any organization which identifies a problem with

patient care which is potentially relevant to training should be

required to inform the training regulator (152)

Recommendation: Statutory duty of co-operation and information

sharing between deanery (?LETB et al) CMG, CQC and Monitor

(153)

+Medical education and training 3

There is a general reluctance to impair the provision of services

through the removal of trainees

Good care is critical for good training. Those with oversight of

training must be aware of the standards of care in

organizations in which they place their students/trainees

Recommendation: Should be standard requirements for routine

visits to training providers. Visits should involved deanery, Royal

College and lay representation, and should be informed by other

sources of info eg CQC (155)

Recommendation: Areas which do not comply with fundamental

patient safety and quality standards should not be allowed to take

trainees or students (162)

+Caring for patients, particularly the

elderly

The elderly seemed to be particularly effected by poor nursing

care

Recommendation: All ward rounds should include the nurse

responsible for those patients (238)

+Summary: for debate

Highly critical in particular of the culture of the Trust

Recommendations

Statutory duty of candour

GPs have duty to monitor standards of care at secondary care facilities.

Is this practical? Is it reasonable?

GMC should investigate when no individuals are named

Something similar to the concept of corporate manslaughter. But how practical is it for the GMC to do this? Such investigations could be extremely large.

Publication of performance data for all clinical teams/consultants

Controversial, there is some evidence that it improves quality of care. But in the UK so far has only been done for surgeons, within specific fields. How practical is this for other specialties?

+For more info…

A cluster of BMJ articles

www.bmj.com/about-bmj/article-clusters/mid-staffs

The public inquiry website.

The executive summary of the report contains a reasonable level of

detail and is very readable.

www.midstaffspublicinquiry.com

The independent inquiry website

www.midstaffsinquiry.com

Review article re performance data and quality of care

http://annals.org/article.aspx?articleid=738899