£10m inquiry ends with criticism of standards and oversight at hospital where as many as 1,200 patients died in four years
It was the biggest scandal of NHS care in years. Several hundred, possibly as many as 1,200, patients died at Stafford Hospital between 2005 and 2009 after suffering neglect, indignity and shoddy care.
Understaffing meant the hospital's A&E unit often posed a risk to patients' safety. A shocking catalogue of appalling care included receptionists assessing emergency cases, patients dying after falling when they were left unattended and some of the sick being denied food and drink.
To compound matters, the hospital's management did little to rectify the situation, while staff were uncaring and lacking in compassion.
It is no wonder that Mid Staffordshire NHS Foundation Trust, which runs the hospital, has become a byword for the dangerously inadequate treatment the NHS sometimes provides.
On Thursday, a 13-monthpublic inquiry into the scandal drew to a close. It has involved 139 days of hearings, 181 witnesses and over a million pages of evidence, and cost over £10m. It ended with severe criticism of almost the entire NHS for not realising earlier what was happening at the hospital, despite an array of what should have been wake-up calls, and then taking action to stop it.
As Tom Kark QC, counsel to the inquiry, said in his closing speech: "There was, it might be thought, throughout the evidence from the major organisations simply a lack of appreciation that their actions and delays had a real effect upon patients lying in beds in the hospital or receiving treatment in A&E."
He was referring to the failings of almost every organisation, and many individuals, in the system of governance that was supposed to ensure the NHS gave patients the best possible medical treatment, and any problems were quickly spotted and solve.
The inquiry, under Robert Francis QC, is the seventh to examine events at Stafford hospital over those years, four of them instigated by the government. Its focus has been not what local patient campaign group Cure The NHS calls "appalling, inhuman care", as that has already been exposed in unsparing detail, but failings of regulation and oversight of the quality and safety of NHS services. Its remit has been to examine "why the serious problems at the trust were not identified and acted on sooner, [and] to identify important lessons to be learnt for the future of patient care".
Francis and his team's investigation into "the role of the commissioning, supervising and regulatory bodies and systems in detecting and correcting deficiencies in service provision" has taken in all the important national and local bodies that patient groups claim should have done more earlier.
They include the Department of Health; health ministers while Labour was in power; the NHS's West Midlands strategic health authority; the Staffordshire town's NHS primary care trust; the Care Quality Commission regulator, which is under heavy criticism over its role in this scandal and other issues; its predecessor, the Healthcare Commission (HCC); and Monitor, which regulates semi-independent foundation trusts. The inquiry has scrutinised "the culture and systems of those organisations in relation to their monitoring role" at Mid Staffs from January 2005 to March 2009.
Francis's final report, due early next year, is likely to criticise many of them. Given the evidence presented, his findings may stain reputations and possibly even end some careers. A previous report he wrote on the appalling care at Mid Staffs was detailed, penetrative and shocking. Few expect less of this one. Andrew Lansley, the health secretary, who asked Francis to undertake this inquiry after his predecessor, Andy Burnham, resisted relatives' calls to do so, has kept a close eye on proceedings.
Local bodies – the trust itself, PCT and local council's health scrutiny committee – have been taken to task for not spotting the scandal or doing nothing about it. But it has also investigated what Jeremy Hyam, Cure's barrister, told the inquiry was "at national level … confusion as to who was responsible for monitoring quality of care. What was at stake was the health, welfare and indeed the lives of patients.
"What was lacking was any real system whereby any organisation took responsibility for what a layperson would describe as keeping an eye on things. All supervisory bodies seem to rely on others, but no one was doing it. We cannot say that the external system for assuring and monitoring the quality of care was inadequate. There was in truth no such system."
The inquiry heard detailed accounts of what Action against Medical Accidents (AvMA), a patient safety charity, calls "catastrophic" failings at the hospital and beyond. There was inaction instead of intervention, neglect of duty rather than vigilance, buck-passing where responsibility was needed, and silence from doctors and nurses when whistleblowing might have helped.
Between 2004 and 2008, A&E staff nurse Helene Donnelly submitted more than 50 reports warning hospital managers about the risks to patients from faulty equipment, untrained staff and lack of staff. Despite always ticking the box on the form saying she wanted feedback, she received none. AvMA said: "Helene Donnelly's managers … didn't take any notice of all those incidents."
Steve Walker, chief executive of the NHS Litigation Authority, told the inquiry how, despite repeated attempts over years to get health professionals to be more open when things went wrong, that message had not got as far as the NHS frontline.
When Stafford A&E doctors treated 20-year-old John Moore-Robinson in 2006 they failed to detect that he had a ruptured spleen, and he died. The trust commissioned a report to find out what went wrong; it criticised his treatment and concluded his death was avoidable. But instead of passing a copy to his parents and the coroner who investigated his death, they kept it secret; compounding grief and obstructing justice in the process.
Julie Bailey, who founded Cure The NHS, played a key role in highlighting the terrible conditions at the hospital after her mother, Bella, died there in late 2007 after suffering poor care. A letter in a local newspaper appealing for others with similar experiences led to her being inundated. She has spent much of the last 13 months attending the inquiry, as well as giving her own evidence, besides running her cafe. In her view, the Mid Staffs scandal is about the failure of a vital system. "The evidence shows that nearly all of the commissioning, supervisory and regulatory bodies and their leaders failed to put patients first."
Only the now defunct Healthcare Commissionmay avoid serious censure by Francis, as its detailed report in early 2009 finally forced ministers and the NHS to instigate changes.
While Mid Staffs was a local matter, it will have widespread ramifications. Evidence has raised serious questions about the professionalism of some NHS staff, including the quality, competence and humanity of nursing care, as other recent reports have done, especially in regard to elderly patients. The NHS's much-criticised complaints system, shown to be hopelessly ineffective in Stafford, is imperfect. And the inquiry has heard calls for NHS staff to be put under a legal "duty of candour" about errors, patient safety alerts to be taken much more seriously and hospitals to be prosecuted for safety lapses.
Yesterday was doubly significant for Stafford. Its A&E unit, implicated in many of the hundreds of needless deaths in 2005-08, has begun closing , every night, between 10pm and 8am. A lack of staff means patients' safety cannot be guaranteed, the trust says. The Guardian