Health Policy InsightEditor's blog Wednesday 24 February 2010: Mid-Stafford report out today - expect fireworks, resignations and legal action
Today will see the publication of the report into the crisis at Mid-Staffordshire NHS Foundation Trust. Update: I've put extracts here.
I've written about Mid-Staffs before: here and here, for example. Assuming that many of the leaks about suppression of incriminating documents and other incidents prove to be true, there should be significant legal consequences for those involved. Wherever they are now. People should go to prison for this one.
The closing submission includes the damning words, "The Inquiry was told that as long ago as 1998, staffing levels at the hospital were acknowledged to be low and in January of 2002, the Commission for Health Improvement published a report following a clinical governance review which expressed concerns about a number of areas.
"These included low staffing levels particularly in nursing, unsatisfactory arrangements for clinical governance, low staff morale, the need for action to ensure privacy and dignity of patients, the need for action to develop an infection control policy and the need for action to ensure an open and learning reporting culture with the identification of trends.
"The Commission for Health Improvement expressed concern that the Trust had concentrated on turning around its financial position and cautioned that there was a need to ensure that quality of patient care was seen as equally important".
Pretty damning.
The report should appear here, on the inquiry website. UPDATE: Apologies for that wrong assumption; it's on the DH website, here, and volume 2 here.
Update: 11.50
It's out. Just reading it. For now, here are the statements form CQC and Monitor:
Joint statement from Monitor and the Care Quality Commission (CQC) on the current position at Mid Staffordshire NHS Foundation Trust: The CQC believes Mid Staffordshire NHS Foundation Trust is safe to provide services. But it has also made it clear that the Trust must address remaining concerns quickly.
On behalf of their patients, the Trust must meet all the essential standards of safety and quality and the CQC will follow up robustly to ensure the trust improves in the areas that need further attention.
CQC and Monitor have strong powers of intervention and would not hesitate to take urgent action to protect patients if they thought this necessary.
The Trust has made important progress since the period described in the Francis Report. Steps have been taken to address immediate risks to patients and the new leadership of the Trust has responded positively. Patients should be keen for their Trust to do better still.
It is important to understand that the scale of change required in this organisation was very significant and was never going to happen overnight. To track progress, the CQC is to carry out another detailed assessment, starting in March, and Monitor continues to hold the Trust’s leadership to account for progress against their transformation plan.
Statement from Monitor: Chris Mellor, Acting Chair of Monitor, said: “There are 126 foundation trusts and the vast majority of them provide safe, high quality care. However, at this Trust, the standard of care that patients received was clearly unacceptable, and the experiences described in this report by patients and their families are incredibly distressing. Absolutely every effort must be made to ensure this never happens again.
“Monitor has taken action at Mid Staffordshire NHS Foundation Trust to put in place new and experienced leadership to drive improvement. We have worked with the Trust to oversee the design and delivery of a transformation plan with clear priorities and rapid actions to secure patient safety.
“The new leadership, which includes a new medical director and nursing director, has already made improvements in patient care, ensuring better infection control, increased numbers of nurses and delivery of a much improved mortality ratio. However, there is still more to do, especially in terms of embedding a new culture of openness, which must be a priority. We are continuing to work with the CQC to track progress at Mid Staffordshire very closely.
“We welcome the Francis Report, and the additional focus it has given to what went wrong at this Trust. We will study the report carefully and where there are new lessons to learn we will work closely with the Trust and the CQC to act on these.
“Following the Healthcare Commission’s report on Mid Staffordshire in March 2009, Monitor commissioned an independent review of lessons learned and made changes to its processes as a result. Changes already made centre on better sharing of information across the healthcare system, in particular between Monitor and the CQC; in addition we are currently consulting on an enhanced approach to quality governance. We have also worked closely with the CQC, Department of Health and others on the National Quality Board report Early Warning Systems in the NHS, published today”.
First up at PMQs
After the Afghanistan death announcements, it's the first David Cameron question. Brown talks of a new system to strike off NHS managers from a register of suitability. There will be proposals about the de-authorisation of foundation trusts. He quotes the CQC statement above.
Statement from Andy Burnhoid to follow.
By way of much-needed light relief
Public health promotion has a very different look to it in La Belle France as this story in The Independent indicates.
Uncharcteristically, I am lost for words.