Extracts from Robert Francis QC’s foreword
“The overwhelming number of accounts given by those affected should surely put to rest the views, still harboured by some, that the Healthcare Commission’s report painted an unfair picture of how the Trust was performing. There can no longer be any excuse for denying the enormity of what has occurred.

“While the number of staff who came forward to assist my Inquiry was disappointing, it is right that their experience and viewpoint should be recorded. Throughout the course of my Inquiry, it has become apparent that many staff, during the period under investigation, did express concerns about the standard of care being provided. The tragedy was that they were ignored.

“The Inquiry has also had the benefit of hearing, and being able to report, the views and thinking of many former and current directors of the Trust. It is clear that many of the problems suffered in this Trust had been in existence for a long time and were known about by those in charge. Many thought – and still think – that they had done their best to address them. While there is no doubt that steps were taken to address many, if not all, of the problems, sadly the action taken was insufficient. I suggest that the board of any trust could benefit from reflecting on their own work in the light of what is described in my report”.

“The Inquiry heard and has reported the many concerns expressed about the role that external agencies play in the oversight of the provision of healthcare. There is undoubtedly further work to be done not only at the Trust, but elsewhere, before public confidence can be assured. Various views have been expressed on whether the Trust is unique or whether other similar stories wait to be uncovered. It is not for me to express a view on that, but the legitimate concerns of those who have suffered in Stafford do need to be addressed”.

“If there is one lesson to be learnt, I suggest it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies are being made and implemented”.

From the executive summary
On witnesses.: “With one exception, all those members of staff who were invited to attend an oral hearing did so. The exception was Mr Yeates, the former Chief Executive, who I was satisfied on medical evidence, including independent medical advice commissioned by the Inquiry, was unfit to attend. However, some written material was furnished on his behalf “

On the complaints: “The complaints were predominantly focused on the accident and emergency (A&E) department, the emergency assessment unit (EAU) and Wards 7, 8, 10, 11, and 12. It was striking how many accounts related to basic nursing care as opposed to clinical errors leading to injury or death”.

On the credibility: “the quality of the evidence given by patients and their families, the dignity and care with which they did so, and the sheer number of similar accounts was highly persuasive. There is no reason to doubt that in the vast majority of cases events occurred as they have been described”

On the culture of the trust: “The culture of the Trust was not conducive to providing good care for patients or providing a supportive working environment for staff. A number of factors contributed to this:
• attitudes of patients and staff – patients’ attitudes were characterised by a reluctance to insist on receiving basic care or medication for fear of upsetting staff. Although some members of staff were singled out for praise by patients, concerns were expressed about the lack of compassion and uncaring attitude exhibited by others towards vulnerable patients and the marked indifference they showed to visitors.
• bullying – an atmosphere of fear of adverse repercussions in relation to a variety of events was described by a number of staff witnesses. Staff described a forceful style of management (perceived by some as bullying) which was employed on occasion.
• target-driven priorities – a high priority was placed on the achievement of targets, and in particular the A&E waiting time target. The pressure to meet this generated a fear, whether justified or not, that failure to meet targets could lead to the sack.
• disengagement from management – the consultant body largely dissociated itself from management and often adopted a fatalistic approach to management issues and plans. There was also a lack of trust in management leading to a reluctance to raise concerns.
• low staff morale – the constant strain of financial difficulties, staff cuts and difficulties in delivering an acceptable standard of care took its toll on morale and was reflected by absence and sickness rates in particular areas.
• isolation – there is a sense that the Trust and its staff carried on much of its work in isolation from the wider NHS community. It was not as open to outside influences and changes in practice as would have been the case in other places and lacked strong associations with neighbouring organisations.
• lack of openness – before obtaining Foundation Trust status, the Board conducted a significant amount of business in private when it was questionable whether privacy was really required. One particular incident concerning an attempt to persuade a consultant to alter an adverse report to the coroner has caused serious concern and calls into question how candid the Trust was prepared to be about things that went wrong.
• acceptance of poor standards of conduct – evidence suggests that there was an unwillingness to use governance and disciplinary procedures to tackle poor performance. The Inquiry has heard of particular incidents of apparent misconduct which were not dealt with appropriately, promptly or fairly.
• reliance on external assessments – The evidence indicates that the Trust was more willing to rely on favourable external assessments of its performance rather than on internal assessment. On the other hand when unfavourable external information was received, such as concerning mortality statistics, there was an undue acceptance of procedural explanations.
• denial – In spite of the criticisms the Trust has received recently, there is an unfortunate tendency for some staff and management to discount these by relying on their view that there is much good practice and that the reports are unfair.

On the experiences and perceptions of staff: “A&E was chronically understaffed in terms of consultants and nurses during the period under review. There were frequent changes in management, which led to a sense of lack of leadership and support of staff. The perception of weak clinical leadership within A&E held by some was unfair to one consultant on whom undue burdens were placed. When more consultants were recruited to ease the pressure, they were emergency physicians who were not qualified to undertake the whole range of A&E duties. The drive to meet the waiting time target had a detrimental effect on staff and on the standard of care delivered. There was persuasive evidence that this even led to attempts to fabricate records”.

“Staff evidence tended to confirm the concerns raised by patients and their families. Among difficulties described were problems in locating a nurse to accompany ward rounds, the pressure from high-dependency patients and the dilution of skills that resulted from reconfiguration. Understaffing was a constant problem and staff even expressed fear about losing their registration because of the unsafe care delivered. Concerns were also expressed about the inappropriate mix of patients on the surgical floor”.

“Staff perceived this scheme (to reconfigure the wards onto three floors, one surgical and two medical) as a means to reduce costs and staff. This was denied by those who proposed the scheme, but it is significant that at the time the initial proposal was approved savings were prominently identified. The minutes of the Board suggest that finance was a crucial factor. It was acknowledged by all concerned that the success of the scheme was dependent on achieving the correct levels of staffing.

“There does not appear to have been an evidence base for the changes that were made. The attraction of the advantages – the financial savings – discouraged proper attention being paid to the disadvantages”.

“The surgical floor was set up without any evidence that a risk assessment of the necessary changes was actually carried out, although the need for it was recognised. Concerns expressed by staff at the time about the proposal were welcomed by directors but were not addressed.

“The Inquiry could not trace any record of the medical floors part of the plan being considered or approved by the Board. In particular, the changes of nursing skill mix, which resulted in a predominance of healthcare assistants over qualified nurses, are not recorded in any Board minute seen by the Inquiry. There were differences of account between executive directors as to who was involved in the decision and the change was disowned by the Director of Clinical Standards, and only nurse on the Board, in evidence to the Inquiry. There was a concerning lack of clarity about the process by which this important decision was taken.

“Once implemented, the medical floors scheme met with widespread disapproval from staff. The evidence strongly suggests that the whole clinical floors project was planned and implemented without due regard to staff’s legitimate concerns and without monitoring by the Board of the effectiveness of the scheme once implemented”.

On finance: “Much of management thinking during the period under review was dominated by financial pressures. The Trust had been facing financial problems for some time before the period under review, with frequent annual deficits. However, a crisis developed at the end of the 2006/07 financial year which led to a need to find cuts of £10 million. It is by no means clear that the only way of finding the necessary savings was to implement a workforce reduction programme. It certainly need not have happened without the involvement of staff and the various departments. Instead, a top-down proposal was launched with departments having to identify cuts to fit the predetermined budget”.

On workforce and staff “The Trust has yet to recover fully from the impact of the staff cuts and changes to skill mix. When these changes were made, the Trust did not have sufficient information about the funded establishment to enable properly informed decisions to be taken. The workforce reduction proposal in 2006 was accompanied by what was called a risk assessment, but on the documents seen by the Inquiry this was superficial and inadequate. The minutes of the Hospital Management Board do not suggest that there was any detailed scrutiny of how the assessment was performed and of its significance. It is also unclear what, if any, engagement executive directors had in this process. When there was a change in Directorship of Clinical Standards/Nursing in December 2006, the new incumbent immediately recognised the need for a workforce review. When completed, it became clear that far from being overstaffed at the time of the workforce reduction the Trust had been understaffed with nurses”.

“The (workforce) review, the need for which was identified in December 2006, was not completed until March 2008. No satisfactory explanation has been given for why it took so long. Even when the findings of the review were received the Board did not react to it with great urgency, seeking to fund the necessary increase in staff in stages, which are still incomplete. The ramifications of this in terms of the standard of care it was possible to deliver appear not to have been sufficiently appreciated”.

On governance: “The investigation of complaints was frequently delegated to staff in the area with which the complaint was concerned. This could result in defensive rather than constructive reports which lacked credibility with complainants who perceived them to lack impartiality. Replies to complaints were often provided too slowly and did not always address all the issues raised. There was a formulaic approach which appeared to value process over substance. Apologies when offered were not always well thought out. Staff who were the subject of complaints did not always have the full details put to them, devaluing any investigation.

“A particularly disturbing feature of the complaints process was that the Trust often did not apply effective remedial action. This is evidenced by a series of complaints raising similar issues in which the response each time was an action plan which, if implemented, would have avoided a subsequent incident. It is difficult to understand how the Chief Executive, if he read the complaints, could have been unaware of systemic failings in the delivery of care. Some letters acknowledged multiple failings. There is no evidence that the substance of complaints were reported to the Board. If they had been told of some of the experiences of those who complained, they would not have been as shocked as they were when finally members of Cure the NHS were able to speak to them directly”.

“Appraisal and professional development were accorded a low priority, as indicated by national surveys. There was evidence that staff were not supported by a robust appraisal system and that continuous professional development was sporadic. There was also evidence of a reluctance to take robust disciplinary action where this appeared to be needed. Concerning cases of alleged misconduct and deficient performance have either not been addressed at all or only in a hesitant manner. This is starkly evidenced by two Royal College of Surgeons’ reviews of the hospital’s surgical division and the dysfunction brought to light by them.

“The few instances of reports by whistleblowers of which the Inquiry was made aware suggest that the Trust has not offered the support and respect due to those brave enough to take this step. The handling of these cases is unlikely to encourage others to come forward, and the responses to the investigation of the concerns raised have been ineffective”.

On the board: “The codes of conduct and guidance for directors make it clear that their duty is to provide strategic direction and that they should refrain from intervening in operational detail, but that they are collectively accountable for all aspects of the performance of the Trust. The Board may have interpreted the division between the strategic and the operational too rigidly, particularly at a time when they were aware that there were serious deficiencies in the governance structure. They may have failed to understand that in such circumstances there will be many instances when a non-executive director can only understand the issues by being informed of operational detail.

“The clinicians taking the role of medical director were reluctant recruits to part-time posts. They may have been handicapped in presenting the professional view to the Board by the disinclination of consultants to engage with management issues. They were not natural leaders and lacked an external perspective which might have alerted them more readily to issues about standards. The registered nurse who had the post of Director of Clinical Standards was unpopular with staff and lacked the confidence of the Chair and was replaced. Her successor may have had a disadvantage in coming from a trust which would have offered fewer challenges and greater support. She was able, however, to demonstrate to the Inquiry that she was conscientious and able to work out what needed to done, although she may have found prompt implementation difficult to achieve. The Director of Operations gave an impression of having focused on individual tasks, such as the achieving of targets, at the expense of leading the overall operation of the Trust”.

“The application for Foundation Trust status was pursued by the Board in part as a means of furthering the need for improvement in governance structures rather than ensuring that the Trust was in a genuinely fit state for the application before embarking on it. There may have been external encouragement to seek Foundation Trust status, but it remained the Board’s duty to ensure that it was an appropriate step to take. The pressures of the process are likely to have distracted the Board from other tasks. The Inquiry does not accept that the Board set out to deceive anyone with the application, but their declarations in relation to the quality of care provided at the Trust revealed a profound misunderstanding of their responsibilities. The focus seems to have been on processes not outcomes”.

“The Board’s reaction to the HCC report was individually and collectively one of denial instead of searching self-criticism. The most common reaction among directors was that the report was unfair because it did not adequately reflect the progress that had been made. During the investigation itself, a degree of complacency was shown and there continued to be a lack of urgency in seeking solutions to the problems identified

On the former chief executive 2005-9, Kevin Yeates: “Although the Chief Executive between January 2005 and March 2009 was not medically fit to attend the Inquiry, documentary material was obtained from which his response to the criticisms of the HCC report could be gleaned, as could the process leading to his departure from the Trust. He asserted that he had been appointed to a failing trust and had achieved a turnaround of the organisation by putting in place a sustainable future, robust governance, and improving quality and standards of care. He considered that the high mortality figures were attributable to coding issues, and that skill mix issues had been identified and were being addressed. Acknowledging that there was work to do, he described the Trust’s culture as being inwardly focused and complacent, resistant to change and accepting of poor standards. He considered the HCC report to be unfair.

"Whatever Mr Yeates may have believed at the time of his departure, in reality the issues raised in this report had not been remedied. He focused on systems, not their outcomes. There was a need for senior management to be deeply involved in service delivery until they could be satisfied that the systems were actually working. He did successfully get to grips with some issues, but the concerns described by both him and his Chair were largely the same as those discerned by the current Chief Executive on his arrival. This does not suggest a successful period of management.

“The Chief Executive stepped aside before being formally suspended by the Board which then commissioned an external report into his performance. Although the report recommended that there was a prima facie case for disciplinary action, the Board decided on pragmatic and commercial grounds to negotiate terms for an agreed departure. The result was that the Chief Executive was also forced out of office without any determination of whether his own performance was in breach of any relevant standards or the code of conduct. There was no public accountability of the type that would be expected in the case of, for instance, a doctor”.

On why nobody outside the trust noticed until the Healthcare Commission: “Concern is expressed that none of them from the PCT to the Healthcare Commission, or the local oversight and scrutiny committees, detected anything wrong with the Trust’s performance until the HCC investigation. While such an investigation is beyond the scope of this Inquiry, local confidence in the Trust and the NHS is unlikely to be restored without some form of independent scrutiny of the actions and inactions of the various organisations to search for an explanation of why the appalling standards of care were not picked up. It is accepted that a public inquiry would be a way of conducting that investigation, but also accepted that there may be other credible ways of doing so”.

Conclusions and recommendations: “A theme of the evidence about the Board has been reliance on the distinction between strategic and operational issues and a disclaimer of responsibility for the latter. The distinction does not justify directors not interesting themselves in operational matters when it is known that governance systems are either not in place or are untested. There was also a lack of clarity about responsibilities for nursing issues.

“The Board’s approach to some problems such as governance was characterised by a lack of urgency. The issues identified in this report required constant follow-up, review and modification. It was unacceptable that the staff review should have been allowed to take so long to complete and implement.

“A common response to concerns has been to refer to generic data or benchmarks such as star ratings, rather than the experiences of actual patients. While benchmarks and data-based assessments are important tools, these should not be allowed to detract attention from the needs and experiences of patients. Benchmarks, ratings and status may not always bring to light serious systemic failings.

“Among other themes the Inquiry has identified from the evidence are:
• a corporate focus on process at the expense of outcomes;
• a failure to listen to those who have received care through proper consideration of their complaints;
• staff disengaged from the process of management;
• insufficient attention to the maintenance of professional standards;
• lack of support for staff through appraisal, supervision and professional development;
• a weak professional voice in management decisions;
• a failure to meet the challenge of the care of the elderly through provision of an adequate professional resource. Some of the treatment of elderly patients could properly be characterised as abuse of vulnerable persons;
• a lack of external and internal transparency;
• false reassurance taken from external assessments; and
• a disregard of the significance of the mortality statistics.