The inquiry into the Staffordshire hospital scandal over “excessive” patient deaths has left questions as to whether such a case could ever happen again in the NHS.

The first alarm over an excessive death rate among emergency admissions at Mid Staffordshire Hospital was first raised in 2008 when a Healthcare Commission (HC) inquiry was launched.

The report released in 2009 flagged up that NHS managers had failed to act over the poor standards of care and conditions at the hospital – and despite failings in patient care and an excessive death rate at Mid Staffs, managers had gone on to receive promotion.

The number of patients who died as a result of poor care at the hospital has never been logged, but it is estimated between 400 and1,200 more deaths occurred between 2005 and 2009, compared with the average death rate for emergency admissions in NHS hospitals.

Following the HC report, New Labour’s Secretary for Health Andy Burnham launched an independent inquiry into the Mid Staffs hospital trust. The result was a list of recommendations published in February 2010, including setting in motion the trust’s de-authorisation to be overseen by the government’s healthcare regulator Monitor.

Families of loved ones who had been treated at Mid Staffs and those who had been bereaved complained that the inquiry into the trust had been held “in camera” and its remit had been narrow.

The average compensation sum to families for their loss was £11,000, but the then Health Secretary called for a further public inquiry entailing the forensic examination of foundation trusts and their commissioning, supervision and regulation.

The coalition government launched the public inquiry in June 2010 and Robert Francis QC examined more than one million pages of evidence and listened to evidence from more than 160 witnesses. The Francis report which followed called for a fundamental change in the culture of care in NHS hospitals, to place patients first.

The damning conclusions of the Francis report also found that NHS bosses had ignored the concerns of patients – and local MPS and GPs had also failed to “fight their corner” over patient care in the NHS.

The Francis report also found that too much faith had been placed in NHS managers by PCTs (primary care trusts) and local health authorities – and NHS regulators at national level had also failed to challenge attitudes and standards in patient care in the NHS.

The Royal College of Nursing (RCN) also came under fire for failing to support nursing staff who tried to raise the alarm about failings in patient care at their own hospitals.

The Department of Health was also criticised for being too remote in managing the NHS – and engaging in reorganisation of the health service which was deemed counterproductive to patient care.

Examples of failing care for patients which the report highlighted included patients being left so thirsty they drank water out of flower vases, receptionists allowed to make potentially life-changing decisions in A&E, nurses allowed to handle complex equipment without sufficient training, inexperienced junior doctors supervising critical care treatment, pain relief left too late to prevent patients experiencing distress and pain, patients left crying for help on wards and patients left to go hungry and thirsty because food and drink was left out of their reach, with no help with feeding at mealtimes.

The appalling inventory of failings and the fact that some NHS staff had concealed data to cover up the truth about excessive death rates and failings in patient care led to the Francis report calling for a criminal charge regarding the manipulation of data in the NHS to cover up failings – with new laws to ensure doctors were transparent when mistakes were made, a code of conduct for senior managers was introduced and a new emphasis on compassion when recruiting, training and educating nursing staff was introduced.

Chief Executive of Mid Staffs hospital trust at the time of the scandal, Sir David Nicholson, was the main witness at the inquiry and maintained that the hospital did not represent a systemic failure in the health service, as it had been the only hospital found with such failings in care.  Counsel for the inquiry called Sir David’s view “naïve and dangerous”.

Sir David is currently CEO of the NHS but will step down from the post by March 2014.

Families who lost loved ones unnecessarily continue to challenge what happened at the Mid Staffs hospital trust.

 


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