A STORY of 'appalling and unnecessary suffering of hundreds of people failed by a system which ignored the warning signs and put corporate self interest and cost control ahead of patients and their safety'.
Those were the words Robert Francis QC used to present the report into his Inquiry into the role of regulators, supervisory bodies and commissioners into the 'disaster' at Stafford Hospital.
"We need a patient-cemtred culture, no tolerance of non-compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership and caring, compassionate nursing, and useful and accurate information about services," said Mr Francis.
He said the evidence at both this inquiry and its predecessor showed patients were let down by Mid Staffordshire NHS Foundation Trust where there was a 'lack of care, compassion, humanity and leadership'.
"The most basic standards of care were not observed and fundamental rights to dignity were not respected," he said. "Elderly, and vulnerable patients were left unwashed, unfed and without fluids. They were deprived of dignity and respect."
"Some patients had to relieve themselves in their beds when they were offered no help to get to the bathroom," he said. "There were incidents of callous treatment by ward staff.
"Patients who could not eat or drink without help did not receive it. Medicines were prescribed but not given."
He said the accident and emergency ward had insufficient staff to deliver safe and effective care and patients were discharged without regard for their welfare.
Mr Francis said the evidence of patients and those close to them was 'shocking' to hear and paid tribute to the dignity with which they presented saying it was important, for them and all others who had suffered to implement the changes necessary to provide the care to which we are all entitled.
He singled out the trust board for their role in 'the disaster at Stafford Hospital', calling them 'weak' and saying they did not listen sufficiently to concerns of patients or staff or tackle problems of poor standards and disengaged senior clinical staff from leadership and management responsibilities.
"These failures were in part due to a focus on reaching targets, achieving financial balance and seeking foundation trust status at the cost of delivering acceptable standards of care," he said.
Mr Francis said the Inquiry had uncovered a failure at all levels of the NHS saying the patient's voice was ignored by the trust and local organisations meant to represent them.
"The local medical community did not raise concerns until it was too late," he said. "Local scrutiny groups were not equipped to understand or represent patient concerns or to challenge reassuring statements issued by the trust."
He said the Primary Care Trust had failed to ensure the quality of health services they were buying and the Strategic Health Authority did not put patient safety at the forefront of its work, preferring to explain away concerns about mortality rates rather than root out matters of concern.
Mr Francis said Monitor had focussed on corporate governance and finance control rather than patient safety and poor care.
He said the Department of Health failed to give Ministers the full picture in supporting the trust's application for foundation trust status calling it 'remote from the reality of service at the front line.' "At every level there was a failure to communicate known concerns adequately to others and to take sufficient action to protect patient's safety and wellbeing from the risks arising from those concerns.
"In short the trust that the public should be able to place in the NHS was betrayed."
Mr Francis went on to say that such a widespread failure could not be blamed on one policy or another, rather it was a culture which 'trumpeted success and said little about failings'.
"What has been found to be wrong here cannot be cured by finding scapegoats and/ or recommending major reorganisations here." said Mr Francis. "What is required now is a real change in culture, a refocusing and recommitment of all who work in the NHS - from top to bottom of the system - on putting the patient first."
Mr Francis said the NHS was a complex organisation subject to frequent reorganising and the last thing it needed was a set of proposals requiring more radical reoganisation.
He said a structure of clearly understood, fundamental standards and measures of compliance with rigorous means of enforcement was neeeded to permit any hospital service to continue.
"Non compliance with these fundamental standards cannot be tolerated," he said. "To cause death or harm to a patient by non-compliance with fundamental standards should be a criminal offence."
He called on the National Institute of Clinical Excellence to develop these standards with the help of relevant professionals and patient groups adding they should include guidance on staffing.
He said the Care Quality Commission should police these standards using trained inspectors rather than the duties of regulation being shared between the CQC and Monitor.
Secondly, Mr Francis called for 'openness, transparency and candour' throughout the NHS including a legal duty of candour underpinned by statute the deliberate obstruction of which should be a criminal offence.
"Every provider trust must be under an obligation to tell the truth to any patient who has or may have been harmed by their care," he said.
"So called 'gagging clauses' which might prevent a concerned employee or ex-employee raising honestly held concerns about patient safety should be banned," he said. "It should be an offence deliberately to give misleading information."
Mr Francis said it was vital improved support for compassionate, caring and committed nursing was provided.
"Entrants to the profession should be assessed for their aptitude to deliver and lead proper care, and their ability to commit themselves to the welfare of their patients," he said. "Named clinicians should be responsible for the welfare and care of each patient in hospital."
Mr Francis said healthcare support workers required proper training and a regulation and registration scheme to prevent those who were unfit to work with patients from doing so.
He said nursing needed a stronger voice and recommended strengthening the profession's representation in organisational leadership.
"I would like to see more recognition of the extremely important role nursing plays in the care of older patients by the creation of new registered status as a registered older person's nurse."
He said strong and patient-centred leadership was necessary to help a proper culture flourish.
"A NHS leadership college could be created," he said. "Offering all potential and current leaders the chance to share in a form of common training designed to equip them to exemplify and implement the common culture."
Mr Francis said information was 'the lifeblood of an open and transparent culture' and said professionals should be obliged to take part in the development of more sophisticated measurements of the effectiveness of what they do.
"Improvements are needed in the core information systems for the collection of data about patients, both to support their individual treatment and the accurate collation of information for statistical purposes," he said. "Difficulties in achieving this are no excuse for inaction."
Mr Francis said while many of the 290 recommendations he had made would take time to develop it was important that they implemented as soon as possible.
"The suffering undergone by patients and those close to them in Stafford demands that the lessons to be learned are not considered for a day or two and then forgotten."
He said while the Government and the Department of Health had a role to play leading those changes, individual organisations in the system could not simply sit back and wait to be told what to do.
""Every single organisation within the NHS and not only those whose actions are described in this report need to reflect from today on what needs to be done differently in the future."
He said every organisation should report publically on a regular basis what they were doing to implement the recommendations.
"My recommendations represent not the end but the beginning of a journey towards a healthier culture in the NHS in which good practice in one place is not considered to be a reason for ignoring poor practice somewhere else; where personal responsibility is not thought to be satisfied by a belief that someone else is taking care of it; where protecting and serving patients is the conscious purpose of everything everyone thinks about day in day out.
"Patients are entitled to be the first and foremost consideration of the system and all those who work in it," he said. "I very much hope that this report and its recommendations will help to bring this about."