The public inquiry into the failings at Mid Staffordshire Trust today concluded that “large numbers of patients were left unprotected, exposed to risk, and subjected to quite unacceptable risks of harm and indignity over a period of years” because the extensive system of checks and balances intended to prevent such failures did not work.

The inquiry, chaired by Robert Francis QC, is critical of all the organisations with both regulatory and statutory responsibility for overseeing hospitals.  But Mr Francis stops short of identifying individuals and, indeed says it is not the place of the inquiry to “seek someone out to blame”.

He writes: “It was not a single rogue healthcare professional who delivered poor care in Stafford, or a single manager who ignored patient safety, who caused the extensive failure which has been identified.

“There were and are a plethora of agencies, scrutiny groups, commissioners, regulators and professional bodies, all of whom have been expected by patients and the public to detect and do something effective to remedy non-compliance with acceptable standards of care.  For years that did not occur.

Read more: Mid Staffs scandal – the key questions

“In short, a system which ought to have picked up deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system.”

Between 400 and 600 more patients than would have been expected died at Mid Staffs trust between 2005 and 2008. A previous independent inquiry by Mr Francis, and before that an investigation by the then Healthcare Commission revealed appalling care, patients humiliated, left in urine soaked beds, a lack of compassion by staff and a management obsessed with meeting targets, its finances and achieving Foundation trust status.

Call for ‘fundamental culture change’

This latest inquiry did not dwell on what happened but on how it happened.  And it makes 290 recommendations as well as calling for “a fundamental culture change”.

Mr Francis rejects the constant refrain from managers and those charged with overseeing and regulating, that no cause for concern was drawn to their attention.  There were ample reports, investigations and warnings.  But there was no sense of urgency in dealing with this, he said.

And he now wants there to be a single regulator and he suggests the Care Quality Commission should take over the role of Monitor, the body charged with regulating foundation trusts.

His report is highly critical of Monitor, which he said should have probed more deeply into what was happening at the trust.

“The wider system did not react to the constant flow of information signalling cause for concern,” the report says.

At the trust itself, Mr Francis said the trust board and others within the trust “failed to appreciate the enormity of what was happening, reacted too slowly, if at all, to some matters of concern of which they were aware, and downplayed the significance of others.”

There was no culture of listening to patients, there were clinicians who kept their heads down, and nobody addressed the risk of shortage of skilled nursing staff.

Mr Francis now recommends that it should be made a criminal offence for any member of the NHS to fail to be open and transparent with patients and relatives or to obstruct another member of staff from speaking out about an incident.

He calls for gagging clauses to be removed from contracts so whistle blowers are not obstructed from speaking out.

And, in a move that will please patient groups, he calls for a statutory duty of candour.  That is, if anyone believes a patient has been harmed or killed, a healthcare worker must let this be known.

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