The following news story appeared in Essentially MIDIRS, vol 4, no 4, April 2013, p24.
The final report into failures of care at Mid Staffordshire NHS Foundation Trust, which contributed to an unacceptably high rate of deaths at Stafford Hospital over a number of years, was published recently.
The inquiry was chaired by Robert Francis QC and its findings reverberated throughout the entire NHS, identifying significant failures of care at every level caused by multiple factors, including: chronic staff shortages; a lack of accountability and a refusal to accept responsibility for failings; poor leadership; and failure to support staff who tried to raise concerns.
Amongst the recommendations made by the inquiry were:
- all NHS staff should be transparent and honest when dealing with both patients and the public, and gagging orders preventing people from speaking out should be banned
- avoidable failures in care that lead to harm or the death of a patient should be dealt with as a criminal offence, not a civil matter
- a common code of ethics, standards and conduct for senior board-level health care leaders and managers should be produced and they should undergo appraisals to ensure they are fit and proper to hold such a position
- Trusts should use evidence-based guidance and benchmarks, where these exist, to ensure that they have adequate staff numbers with sufficient skills in place
- patients should be put first and the chain of responsibility for each service user made manifest
- a system of registration should be introduced for health care support workers who should be trained in accordance with common standards and be clearly distinguishable from registered nurses.
These recommendations were welcomed by Cathy Warwick, Chief Executive of the Royal College of Midwives, who commented on several of the issues raised: ‘The recommendation to introduce a new duty of candour is an excellent suggestion. We hear far too often from midwives who are genuinely petrified about raising the alarm bell over poor quality of care. They fear that senior managers will come down on them hard simply for raising concerns. We need to transform the culture of the NHS so that midwives and others who need to raise concerns feel happy and secure in doing so. NHS staff must never again be afraid to raise concerns about standards of NHS care. Today must be a watershed for the NHS’.
‘It is good news too to see a tough new system that will hold senior managers in particular accountable for their actions. The power to disqualify those who prove themselves unfit to manage the NHS is a massive step forward and matches the rules that currently apply to midwives and are being rolled out to doctors’.
‘We welcome that NICE will be asked to set minimum safe staffing levels for the NHS. For too long the NHS in England has been thousands of midwives short, and we are at the edge of safe care. Minimum safe staffing levels for maternity care, for example, will mean that finally the NHS will be forced to recruit the midwives and other NHS staff needed to provide safe care’.
‘It is also good to see Francis recommend the regulation of health care assistants, such as maternity support workers. The safety of people being cared for by the NHS must be paramount and regulating all those providing care helps achieve that’.
The report was critical of the NMC’s poor regulatory function, stating, ‘both the public and professionals may also be deterred from referring cases by the apparent complexity of the process and the time taken to resolve cases’ (2013:58) and it highlighted a ‘…need to develop their capacity to examine and investigate concerns even where no named individual has been identified to them’ (2013:59). The NMC acknowledged its past failings and Chief Executive, Jackie Smith said: ‘The NMC needs to change… we believe that a new framework should aim for a faster, more flexible and fairer system, which would robustly protect patients and the public interest’.
Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: executive summary. London: The Stationery Office. http://tinyurl.com/bkgyem7 [Accessed 25 February 2013].