THE publication of the Francis Report into the scandal at Stafford Hospital today revealed 'serious failures' on the part of the trust board to ensure the correction of failings at the trust.
In a letter to the Secretary of State for Health opening the report Robert Francis QC, who chaired the inquiry, said: "Above all, it [The Trust] failed to tackle an insidious, negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities."
He said that failure was in part due to a focus on national targets, achieving financial balance and seeking foundation trust status at the cost of delivering acceptable standards of care.
"The story would be bad enough if it ended there, but it did not," he said. "There are a plethora of agencies, scrutiny groups, commissioners, regulators and professional bodies, all of whom might be expected by patients and the public to detect something effective to remedy non compliance with acceptable standards of care.
"For years that did not occur, and even after the start of the Healthcare Commission investigation, conducted because of the realisation that there was serious cause for concern, patients were, in my view, left at risk with inadequate intervention until after the completion of that investigation a year later."
He said the system had failed in its primary duty to protect patients and maintain confidence in the healthcare system.
Mr Francis said his report identified numerous warning signs which should have alerted the system to problems at the trust and the reason they didn't was based on a number of factors including
- a culture focused on business and not patients
- a system more interested in positive data than warning signs
- standards and methods of measuring compliance which did not focus on the effect on patients
- a high tolerance for poor standards
- a communications break-down between organisations that should have been sharing information
- assumptions that monitoring and intervening over poor performance was someone else's duty
- a failure to build a positive culture - particularly in nursing
- a failure to understand the risks of restructuring especially in regard to the loss in 'corporate memory' that could create.
Mr Francis goes on to say the aim of the recommendations made in the report are to:
- Foster a common culture where patients are put first
- Develop a set of fundamental standards of care, the breach of which should not be tolerated
- Provide professionally based and evidence-led means of compliance with these standards
- Ensure openness, transparency and candour throughout the system over matters of concern
- Ensure the focus of regulators is on policing compliance with standards
- Make accountable all who provide care and ensure the public is protected from those not fit to provide care
- Make senior managers and leaders accountable for protecting patients interests
- Enhance recruitment, education, training and support - particularly in nursing and leadership - to take on shared values of common culture.
- Develop and share methods of measuring performance
"The extent of the failure of the system shown in this report suggests that a fundamental culture change is needed," he said. "This does not require a root and branch reorganisation but it requires changes which can largely be implemented within the system that has now been created by the new reforms."
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