Mid Staffordshire NHS Foundation Trust Public Inquiry
(asked on 8th June 2016) - View Source
Question to the Department of Health and Social Care:
To ask the Secretary of State for Health, how many recommendations of the report of the public inquiry into Mid Staffordshire NHS Foundation Trust have not been implemented.
In 2010, Sir Robert Francis began his inquiry into failings at the Mid Staffordshire NHS Foundation Trust, the report of which was published in 2013. “Patients First and Foremost”, the Government’s initial response, was published shortly afterwards; followed later in the year with a more detailed response “Hard Truths: The Journey to Putting Patients First”.
These are available at:
In February 2015, the Government published “Culture Change in the NHS” (link), a consolidated account of the progress to date in implementing the recommendations committed to. These actions fell into a few broad categories – for example, improving professional regulation and oversight; introducing a professional duty of candour; developing a more integrated and collaborative approach to quality regulation; increasing co-operation with regulators across and outside the health and care sector; and addressing the urgent need for a different culture in the National Health Service, one with a greater emphasis on putting the patient at the heart of services, where professionals focus on learning from experience, and where accountability and transparency are valued and become an integral part of clinical practice.
In July 2015, the Government also published “Learning not Blaming” (link), our response to Sir Robert Francis QC’s “Freedom to Speak up” report (link), the report of Dr Bill Kirkup into events at Morecambe Bay (link), and the Public Administration Select Committee’s report into the investigation of clinical incidents (HC886, 27 March 2015), all of which had been published earlier that year. The themes identified in “Learning not Blaming” were similar to those found in Sir Robert Francis’s report into Mid Staffordshire NHS Foundation Trust, in particular the repeated failure of professionals to heed the concerns of their patients and of their colleagues.
The Government has supported the health and care system in successfully making the culture changes that Sir Robert called for. Although the journey outlined in these reports is still under way, the system continues to make significant and worthwhile progress, which the Government wholeheartedly support, including:
- consolidating NHS provider regulation into one organisation – NHS Improvement (NHSI) – that will lead the development of a culture that focuses on improving outcomes, efficiency and fairness; and that, in doing so, emphasises learning from experience;
- locating the NHS patient safety function in NHSI, and creating a new Healthcare Safety Investigation Branch, headed by an independent chief investigator;
- setting up the office of the Independent National Officer, to protect whistleblowers;
- reforming the system of midwifery supervision, to bring it into line with other professions;
- establishing a global movement to improve patient safety;
- leading the development of a more open and transparent approach to the handling of all feedback (including complaints) across the NHS;
- starting the process of improving the systematic recording and tracking of perinatal deaths; and
- further developing the use of data and insight to inspire improvement in quality and efficiency, and help hospital leaders at Board level to understand what more needs to be done in their organisation to earn the title of ‘learning organisation’.
The Government remains committed to creating the safest, highest quality care healthcare services. We have taken the actions necessary to support the health and care system in rising to the challenge of making the journey to putting patients first.