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Robert Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust

  • Document type:
    Report
  • Author:
    The Mid Staffordshire NHS Foundation Trust Inquiry
  • Published date:
    24 February 2010
  • Publication format:
    A4
  • Product number:
    ISBN 978-0-10-296439-4
  • Gateway reference:
    13743
  • Pages:
    822
  • Copyright holder:
    Crown

Robert Francis QC has today published his Inquiry report into Mid-Staffordshire NHS Foundation Trust.  His Inquiry followed concerns about standards of care at the Trust, and an investigation and report published by the Healthcare Commission in March 2009.  Robert Francis has heard evidence from patients, their relatives and staff to inform his report and the 18 recommendations he makes. The Department of Health and the Trust Board has accepted the recommendations of the Inquiry in full.

To support all NHS organisations to learn from and respond to the recommendations of the report, three reports have been published that help embed effective governance and detect and prevent such serious failures occurring again. These reports are:

Review of Early Warning Systems in the NHS
This describes the systems and processes, and values and behaviours which make up a system for the early detection and prevention of serious failures in the NHS.  It emphasises that everyone has a role to play – from doctors and nurses, to commissioners in PCTs, system managers in SHAs and DH, and the regulators – in safeguarding quality of care to patients

Assuring the quality of senior NHS managers
This report of a working group sets out recommendations to further raise the standards of senior NHS managers.  The report recognises that while the overwhelming majority of NHS managers meet high professional standards everyday, a very small number sometimes demonstrate performance or conduct that lets down the patients they serve as well as their staff and organisations.  The group's recommendations include replacing the Code of Conduct for NHS managers with a new statement of professional ethics and consultation on a system of professional accreditation for senior NHS managers.

The Healthy NHS Board
The document sets out the guiding principles that will allow NHS board members to understand the collective role of the board, governance within the wider NHS, approaches that are most likely to improve board effectiveness, and the contribution expected of individual board members.

Responding to some of the specific recommendations in the report, the Secretary of State has accepted Robert Francis's recommendation to consider asking Monitor to de-authorise Mid-Staffordshire NHS Foundation Trust.

His strong view, in the light of the Inquiry report and the support that the Trust is likely to need in the medium and long term, is that he will ask Monitor to consider de-authorising when the powers come into effect in the coming months.  He will therefore ask the CQC, Monitor and others to give him their views of the Trust's long-term clinical and financial prospects, and will consider initiating the process in the light of their responses.

The Inquiry raised questions over the role of external organisations. Recommendation 16 of the report recommends a further Independent Inquiry of the commissioning, supervisory and regulatory bodies.  Secretary of State has proposed that Robert Francis QC chairs this Inquiry and he has agreed to do so.  Draft terms of reference are published today, seeking comments from interested parties.  Robert Francis will lead a scoping exercise before terms of reference are finalised and the Inquiry commences formally.

The report highlights the consequences of poor board performance on patient care and recommendation 9 makes clear the need for a regulatory and accreditation scheme for senior NHS managers that mirrors those in place for clinicians and nursing staff.  One of the proposals contained in Assuring the quality of NHS senior managers is to consult on a new system of accreditation for managers that aims to provide stronger assurance of the quality of senior managers in the NHS.

Professor Sir Bruce Keogh has established a working group to look at the complicated issue of Hospital Standardised Mortality Ratios (HSMRs) and develop a single HSMR methodology for the NHS, which is raised in the Inquiry report.

The group will include key groups involved in developing and using HSMRs as well as leading academics and other interested parties for example Dr Foster, the Academy of Medical Royal Colleges, the CQC and Monitor. The group will report back to the National Quality Board on progress.  In addition, the NHS Confederation will be developing a practical guide to using and interpreting HSMRs.  An interim statement on HSMRs is published today signed by key parties.

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