Mid Staffs hospital scandal: the essential guide

Mid Staffs hospital scandal: the essential guide: With a new inquiry into the causes of poor care at the hospital being released, the findings may have ramifications for the rest of the NHS. Study the issue in depth and learn all you need to know about what happens next with our essential guide.

1. What is the Mid Staffs scandal?
2. Why is it in the news again now?
3. How did the poor care come to light?
4. The public inquiry
5. The first Francis inquiry: what was care like?
6. What did the Healthcare Commission find?
7. Why was care so bad?
8. So who failed to spot problems at Stafford and/or do enough to stop them?
9. How will the Mid Staffs scandal affect the NHS?

1. What is the Mid Staffs scandal?

An estimated 400-1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009 at Stafford hospital, a small district general hospital in Staffordshire. The report being published on 6 February 2013 of the public inquiry chaired by Robert Francis QC will be the fifth official report into the scandal since 2009, and Francis's second into the hospital's failings.
The often horrifying evidence that has emerged means "Mid Staffs" has become a byword for NHS care at its most negligent. It is often described as the worst hospital care scandal of recent times. In 2009 Sir Ian Kennedy, the chairman of the Healthcare Commission, the regulator of NHS care standards at the time, said it was the most shocking scandal he had investigated.
It is commonly known as the Mid Staffs scandal because Stafford hospital was and is run by the Mid Staffordshire NHS hospital trust, which in 2008 acquired foundation trust status, making it semi-independent of Department of Health (DH) control. Decision-making and especially cost-cutting as part of its pursuit of that status was later cited as a key reason why poor care took hold and was allowed to persist for so long.
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2. Why is it in the news again now?

On Wednesday 6 February Francis will publish the report of his 31-month-long public inquiry into the scandal. His first report, published in February 2010, was an independent report under the NHS Act rather than a full-blown public inquiry. It examined the quality of care at Stafford hospital in 2005-09 and the many reasons why it was so bad, such as inadequate staffing, and produced devastating conclusions.
The public inquiry began in July 2010. Its remit was to investigate what a wide range of commissioning, supervisory and regulatory bodies and systems in the NHS had done to detect poor care at Stafford and to intervene. As such it probed the role of the bodies and individuals all the way from the hospital itself – including the trust's board and its patient liaison group – up to the most senior figures at the Department of Health in Whitehall, including ministers, senior civil servants and key figures in the NHS.
Its brief included its duty "to examine why problems at the trust were not identified sooner; and appropriate action taken. This includes, but is not limited to, examining the actions of the Department of Health, the local Strategic Health Authority, the local primary care trust(s), the Independent Regulator of NHS Foundation trusts (Monitor), the Care Quality Commission, the Health and Safety Executive, local scrutiny and public engagement bodies and the local coroner."
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3. How did the poor care come to light?

Although care was poor from at least the start of 2006, concerns about that only began emerging in mid-2007. At that time the Healthcare Commission (HCC), the then NHS care regulator, became anxious that Stafford seemed to have unusually high death rates, drawing on information from Professor Brian Jarman, an expert in patient safety and hospital death rates at Imperial College London.
By January 2008 the watchdog had identified seven different patient safety alerts at Stafford: warning signs that there were problems. Dissatisfied with the hospital's explanation for the apparently high mortality rate – that it was down to "coding errors" – the HCC told a team of its investigators under Heather Wood, renowned as its "hard cases woman", to get to the bottom of what was happening at the hospital. That was the first of the five inquiries.
Julie Bailey, whose 86-year-old mother Bella died in the hospital as a result of poor care in late 2007, also played a key role in exposing the Mid Staffs scandal. She quickly came across other families who had lost a loved one, realised there was a problem and, with other bereaved relatives, formed the campaign group Cure The NHS to demand a public inquiry and hold those reponsible to account.
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4. The public inquiry

Andrew Lansley, the then health secretary, commissioned the full public inquiry in June 2010, soon after the coalition took power. It was held under the Public Inquiries Act 2005. Labour in 2009 and 2010 had refused to accede to persistent requests from relatives of victims of the Mid Staffs scandal to hold such an inquiry. Instead ministers commissioned the first Francis report as well as two other, separate inquiries into specific aspects of how the hospital and local healthcare system operated. They were led by Professor George Alberti, the DH's national clinical director for emergency care, and Dr David Colin-Thome, his counterpart at the DH for primary care. They reported in April 2009.
Francis began gathering evidence in July 2010. He initially hoped to deliver a report to ministers by early 2011. Instead it became a particularly in-depth and long-running inquiry. The inquiry took oral evidence from 164 witnesses over the 139 days it sat between November 2010 and December 2011, and also received 87 witness statements and 39 provisional statements, and over a million pages of evidence in total.
Tom Kark QC, counsel to the inquiry, and Francis himself questioned witnesses.
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5. The first Francis inquiry: what was care like?

Francis's report into care at Stafford hospital in February 2010, based on evidence from over 900 patients and families, was scathing. "I heard so many stories of shocking care," he said. "They were people who entered Stafford hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives."
Francis cited a litany of failings in the care of patients. "For many patients the most basic elements of care were neglected," he said. Some patients needing pain relief either got it late or not at all. Others were left unwashed for up to a month. "Food and drinks were left out of the reach of patients and many were forced to rely on family members for help with feeding." Too many patients were sent home before they were ready to go, and ended up back in hospital soon afterwards. "The standards of hygiene were at times awful, with families forced to remove used bandages and dressings from public areas and clean toilets themselves for fear of catching infections." Patients' calls for help to use the toilet were ignored, with the result that they were left in soiled sheeting or sitting on commodes for hours "often feeling ashamed and afraid". Misdiagnosis was common.
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6. What did the Healthcare Commission find?

Care at Stafford was "appalling", the watchdog's report said. The Guardian reported at the time that it found "inadequately trained staff who were too few in number, junior doctors left alone at night and patients left without food, drink or medication as their operations were repeatedly cancelled. Receptionists with no medical training were expected to assess patients coming in to A&E, some of whom needed urgent care."
The then health secretary Alan Johnson said there had been "a complete failure of management to address serious problems and monitor performance, [which] led to a totally unacceptable failure to treat emergency patients safely and with dignity". Bruce Keogh, the NHS's medical director, condemned the trust's "complete failure of leadership". HCC chairman Sir Ian Kennedy said its report was "a shocking story … of appalling standards and chaotic systems for looking after patients. These are words I have not previously used in any report."
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7. Why was care so bad?

"A chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care," Francis found in his first report.
In addition, morale was low and "while many staff did their best in difficult circumstances, others showed a disturbing lack of compassion towards their patients", he added. "Staff who spoke out felt ignored and there is strong evidence that many were deterred from doing so through fear and bullying."
He laid much of the blame on the trust's ruling board. The action they took to investigate and resolve concerns "was inadequate and lacked an appropriate sense of urgency". Its members also "chose to rely on apparently favourable performance reports by outside bodies, such as the Healthcare Commission, rather than effective internal assessment and feedback from staff and patients". He was particularly critical of the trust's failure to take patients' complaints seriously enough.
Crucially, Francis also highlighted the key impact of the trust board's decision to try to save £10m in 2006-07, as part of its desire to gain foundation trust status. "The board decided this saving could only be achieved through cutting staffing levels, which were already insufficient." It also ignored staff's concerns, he added.
He also mentioned that "many people expressed alarm at the apparent failure of external organisations to detect any problems with the trust's performance" and recommended a separate inquiry look into that.
That led directly to the latest Francis inquiry, which reports on Wednesday 6 February.
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8. So who failed to spot problems at Stafford and/or do enough to stop them?

The report of the public inquiry is likely to find that almost every link in what should have been the NHS's chain of monitoring and scrutinising hospital care, and intervening if necessary, did not do its job properly. He has investigated the actions of scores of bodies and individuals, both locally and nationally. The record, performance and reputation of many of them are likely to face detailed criticism, including the management and board of the hospital itself, the various regulators involved (Healthcare Commission, its successor the Care Quality Commission and Monitor) and senior figures at the Department of Health.
As Francis's first report said, that inquiry heard evidence "that none of them [external organisations charged with overseeing the trust], from the PCT to the Healthcare Commission, or the local oversight and scrutiny committee, detected anything wrong with the trust's performance until the HCC investigation." The landmark report will, over many hundreds of pages, detail what he then also called "the actions and inactions of the various organisations to search for an explanation of whay the appalling standards of care were not picked up."
His task is to explain why so many people failed so badly, and to make sure it does not happen again.
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9. How will the Mid Staffs scandal affect the NHS?

Francis's new report will prompt much soul-searching about why some NHS organisations end up providing inadequate, inhumane and dangerously substandard care to some or many patients. Many people will say in effect "Mid Staffs must never happen again", and Francis will set out how to ensure this is the case. It comes amid rising concern about care, and the behaviour of some of the NHS's huge workforce, which was encapsulated by health secretary Jeremy Hunt that "the crisis in standards of care" - not coping with rising demand at a time of tight budgets or making £20bn of efficiency savings by 2015 or reconfiguring hospital services so more patients can be treated in or near their homes - was the service's biggest challenge.
David Cameron and Jeremy Hunt will doubtless point to initiatives they have taken - such as bringing in a "friends and family" test of hospital care and exploring tough "Ofsted-style" ratings for hospitals - as having at least started to tackle the problems Francis has spent so long pursuing.
But his recommendations are likely to go further than this. Ministers, NHS regulators and the new NHS Commissioning Board are already debating the merits of changes that have been proposed from various quarters such as regulation of healthcare assistants, legal minimum staffing levels on NHS wards, a legally-binding "duty of candour" on all NHS staff to admit to mistakes, a blacklist of failed NHS managers and many others. However, if Francis decides that in effect NHS regulation at the time failed - he can hardly conclude otherwise - then ministers may come under pressure to introduce much more robust regulation. That, though, is opposed by bodies such as the NHS Confederation, which represents hospitals, and National Voices, an alliance of 130 charities. The Guardian