Sir Robert Francis published the report of the independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009.
The inquiry had been set up by former Secretary of State Andy Burnham following considerable public concern and loss of confidence in the management of the trust. The inquiry followed the publication of a highly critical report by the Healthcare Commission in 2009 and two further reviews commissioned by the Department of Health.
The inquiry heard witness accounts of bad care, denial of dignity and unnecessary suffering, suggesting that all of the inquiry team had been deeply affected by what they had heard. As an example, Francis heard many patient stories relating to a lack of concern regarding continence care, leading him to suggest that at best staff were defensive and at worst uncaring about delays in attending to the continence needs of their patients.
The inquiry identified that there had been:
- a focus on process at the expense of outcomes
- a failure to properly consider complaints
- a workforce that was disengaged from the process of management
- an insufficient focus on the maintenance of professional standards
- a lack of support for staff
- a weak professional voice in management decisions
- a failure to meet the care needs of elderly people
- a lack of transparency
- false reassurance taken from external assessment at the same time as a significant disregard of the significance of mortality statistics.
Francis was particularly critical of the high priority placed on the achievements of targets, particularly on A&E waiting times, and suggested that the pressure to meet targets generated fear among the workforce that staff would be sacked if targets were not met. Regarding this, Sir Robert said, ‘I found evidence of the negative impact of fear, particularly of losing a job, from top to bottom of this organisation. Regrettably, some of the causes of that fear have arrived at the door of the trust from elsewhere in the NHS organisation in the form of financial pressures and fiercely promoted targets.’
Francis was scathing about the culture and leadership of the trust, suggesting that there was an atmosphere of bullying, disengagement from management, low staff morale, isolation and an acceptance of poor standards.
While the terms of reference of the first independent inquiry were focused on the internal workings of the trust, Francis highlighted the need for the government to provide some form of identity scrutiny of the actions and inactions of the various organisations who were in contact with the trust in order to understand why the appalling standards of care had not been identified and acted upon sooner.