NHS staff should face prosecution if they are not open and honest about mistakes, according to a public inquiry into failings at Stafford Hospital.Years of abuse and neglect at the hospital led to the unnecessary deaths of hundreds of patients.
The “appalling” levels of care that led to needless deaths have already been well documented by a 2009 report by the Healthcare Commission and an independent inquiry in 2010, which was also chaired by Mr Francis.
They both criticised the cost-cutting and target-chasing culture that had developed at the Mid Staffordshire Trust, which ran the hospital.
But inquiry chairman, Robert Francis QC, said the failings went right to the top of the health service.
He made 290 recommendations, saying “fundamental change” was needed to prevent the public losing confidence.
His report comes after the families of victims have voiced anger that no-one has been sufficiently punished for their roles.
Senior managers were able to leave the trust with little sanction, while most doctors and nurses involved have escaped censure from their professional regulators.
Responding in the House of Commons, Prime Minister David Cameron apologised to the families of patients.
He said he was “truly sorry” for what happened at Stafford Hospital, which was “not just wrong, it was truly dreadful” and the government needed to “purge” a culture of complacency.
Mr Cameron said a full response to the inquiry would follow next month, but he did immediately announce that a new post of chief inspector of hospitals would be created in the autumn.
The final report contains 290 recommendations over nearly 1,800 pages. In particular, it recommended:
- The merger of the regulation of care into one body – two are currently involved
- Senior managers to be given a code of conduct and the ability to disqualify them if they are not fit to hold such positions
- Hiding information about poor care to become a criminal offence as would failing to adhere to basic standards that lead to death or serious harm
- A statutory obligation on doctors and nurses for a duty of candour so they are open with patients about mistakes
- An increased focus on compassion in the recruitment, training and education of nurses, including an aptitude test for new recruits and regular checks of competence as is being rolled out for doctors
While it is well-known the trust management ignored patients’ complaints, local GPs and MPs also failed to speak up for them, the inquiry said.
The local primary care trust and regional health authority were too quick to trust the hospital’s management and national regulators were not challenging enough.
Meanwhile, the Royal College of Nursing was highlighted for not doing enough to support its members who were trying to raise concerns.
The Department of Health was also criticised for being too “remote” and embarking on “counterproductive” reorganisations.
Instead, it urged everyone from “porters and cleaners to the secretary of state” to work together to shift the culture and adopt a “zero tolerance” approach to poor care.
Mr Francis said: “This is a story of appalling and unnecessary suffering of hundreds of people. They were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.”
He said the public’s trust in the NHS had been “betrayed” and a change of culture was needed to “make sure that patients come first”.