Francis Report – a catalogue of shame

In 2013, Care, NHS on February 6, 2013 at 2:40 pm

The Report of the Inquiry into the Mid-Staffordshire Scandal was published today. In his statement, Robert Francis QC said ‘This is a story of appalling and unnecessary suffering of hundreds of people. They were failed by a system which ignored the warning signs and put corporate self interest and cost control ahead of patients and their safety. I have today made 290 recommendations designed to change this culture and make sure that patients come first.’

The scale of the failures in Patient Care had been exposed by the earlier Inquiry, the focus here is how it could be that the failures went unnoticed, unchallenged and unaddressed for so long. The Report makes it clear that there was a major failure of governance from the Trust board, whose members have already been removed from office. However, the problems are deeply rooted in a cultural malaise in which the quality of care for patients ceased to be the primary focus of the organisation. Too many people, not just managers and professionals, tolerated unacceptable standards of care. The systems designed to give voice to patient perspectives failed. Performance management lost sight of patient care in a focus on financial control and high level targets. Regulatory oversight was both fragmented and unco-ordinated.

This is a crisis of values and requires sober reflection, acceptance of responsibility and concerted action to create a common purpose around high quality patient care. As the Report says, a ‘culture of caring requires a displacement of a culture of fear with a culture of openness, honesty and transparency’ Para 1.180.

Robert Francis will be in Southampton on 4 March to reflect on the Report and its significance at the inaugural Hickman & Rose/Centre for Law, Ethics and Globalisation lecture. We look forward to exploring it with him.

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