Mid Staffs inquiry: how a 10-year cover-up was uncovered

The truth is out – thanks to the persistence of a group of relatives

The appalling care and neglect uncovered at Stafford Hospital did not develop overnight. Warning signs had been in evidence for years but were ignored or overlooked by every organisation responsible for regulating the NHS, up to and including the Department of Health.

As early as 2002, the Commission for Health Improvement published a highly critical report describing a lack of governance, poor culture and some staff “under constant pressure”.

Its successor, the Healthcare Commission, nevertheless failed to detect the scale of the unfolding disaster for most of its existence from 2004 to 2009 because it was over-reliant on self-assessment by trusts of their performance, the inquiry said.

Staff who did speak out were ignored. Helen Donnelly, an accident and emergency nurse, told the inquiry she had raised concerns about poor care in 2007, provoking a hostile reaction from colleagues – who warned her to “watch her back”.

Chris Turner, a junior doctor in A&E in 2007, described the department as “an absolute disaster” and “immune to the sound of pain”. He repeatedly complained to managers at the trust and eventually contacted the West Midlands postgraduate dean, but nothing happened.

Peter Daggett, a consultant physician, repeatedly raised concerns with management over a number of years. He too was ignored but he did not take his concerns to a higher level.

Meanwhile death rates at the trust had been rising; by 2007 they were 27 per cent above the national average. It is estimated that the number of deaths at the hospital was 492 more than would have been expected between 2005 and 2008, and as many as 1,200 more between 1996 and 2008.

This should have rung alarm bells and prompted a detailed investigation. Instead, the trust commissioned a report from academics at Birmingham University who cast doubt on the relevance of the figures. At a subsequent board meeting the trust concluded that “no clinically significant problems” could be attributed to the high death rate.

The same year, Julie Bailey, whose mother, Bella, had died at the hospital in terrible circumstances in 2006, founded the local patient pressure group “Cure the NHS” to provide a voice for grieving families whose complaints had been ignored.

The group described patients left screaming in pain, lying in soiled sheets, unwashed and unfed, and so dehydrated that they had to drink water from flower vases. It was the group’s campaigning, more than any other single factor, that led to the scandal being exposed.

The trust board was deaf to its entreaties as its focus was on hitting targets for waiting times and achieving financial stability so that it could gain foundation status. Monitor, the NHS economic regulator, was unaware of the concerns growing in the Healthcare Commission about quality of care, and granted it foundation status in 2008.

That allowed Martin Yeates, former chief executive of the trust, to declare: “We have joined the premier league.”

It was not to be for long. The Healthcare Commission, finally stung into action, had started its investigation. “The truth was uncovered … mainly because of the persistent complaints made by a very determined group of patients and those close to them… [who] wanted to know why they and those close to them had been failed so badly,” the report says.

The Healthcare Commission report in 2009, which finally exposed the scandal, was followed by the first independent inquiry, chaired by Robert Francis. In its February 2010 report the inquiry described a “bullying culture” that was “target focused” in which the needs of patients were ignored.

“An appalling failure at every level,” Mr Francis concluded.

Yesterday’s report of the public inquiry, announced in June 2010 and also chaired by Robert Francis, concluded that the failure extended to every level of the NHS, from the trust board, the regulators and the health authorities to the Department of Health.

His solution, set out in 290 recommendations, is not another root and branch reorganisation – “the system has had many of those” – but a change of culture to ensure patients come first, based on zero tolerance of poor care; openness and transparency; a duty of candour to patients; caring, compassionate nursing; and useful and accurate information about services.

Suggested Topics
Voices
Homeless Veterans charity auction: Cook with Angela Hartnett and Neil Borthwick at Merchants Tavern
charity appeal
Sport
Amir Khan is engaged in a broader battle than attempting to win a fight with Floyd Mayweather
boxing Exclusive: Amir Khan reveals plans to travel to Pakistan
Arts and Entertainment
Caroline Flack became the tenth winner of Strictly Come Dancing
tvReview: 'Absolutely phenomenal' Xtra Factor presenter wins Strictly Come Dancing final
Sport
Ched Evans in action for Sheffield United in 2012
footballRonnie Moore says 'he's served his time and the boy wants to play football'
PROMOTED VIDEO
Life and Style
ebookNow available in paperback
Life and Style
ebooksA superb mix of recipes serving up the freshest of local produce in a delicious range of styles
Latest stories from i100
Have you tried new the Independent Digital Edition apps?

ES Rentals

    Independent Dating
    and  

    By clicking 'Search' you
    are agreeing to our
    Terms of Use.

    iJobs Job Widget
    iJobs General

    Recruitment Genius: Finance Director

    £65000 - £80000 per annum: Recruitment Genius: Finance Director required to jo...

    Recruitment Genius: Medico-Legal Assistant

    £15000 - £25000 per annum: Recruitment Genius: This is a unique opportunity fo...

    Ashdown Group: (PHP / Python) - Global Media firm

    £50000 per annum + 26 days holiday,pension: Ashdown Group: A highly successful...

    The Jenrick Group: Quality Inspector

    £27000 per annum + pension + holidays: The Jenrick Group: A Quality Technician...

    Day In a Page

    Amir Khan: 'The Taliban can threaten me but I must speak out... innocent kids, killed over nothing. It’s sick in the mind'

    Amir Khan attacks the Taliban

    'They can threaten me but I must speak out... innocent kids, killed over nothing. It’s sick in the mind'
    Homeless Veterans appeal: 'You look for someone who's an inspiration and try to be like them'

    Homeless Veterans appeal

    In 2010, Sgt Gary Jamieson stepped on an IED in Afghanistan and lost his legs and an arm. He reveals what, and who, helped him to make a remarkable recovery
    Could cannabis oil reverse the effects of cancer?

    Could cannabis oil reverse effects of cancer?

    As a film following six patients receiving the controversial treatment is released, Kate Hilpern uncovers a very slippery issue
    The Interview movie review: You can't see Seth Rogen and James Franco's Kim Jong Un assassination film, but you can read about it here

    The Interview movie review

    You can't see Seth Rogen and James Franco's Kim Jong Un assassination film, but you can read about it here
    Serial mania has propelled podcasts into the cultural mainstream

    How podcasts became mainstream

    People have consumed gripping armchair investigation Serial with a relish typically reserved for box-set binges
    Jesus Christ has become an unlikely pin-up for hipster marketing companies

    Jesus Christ has become an unlikely pin-up

    Kevin Lee Light, aka "Jesus", is the newest client of creative agency Mother while rival agency Anomaly has launched Sexy Jesus, depicting the Messiah in a series of Athena-style poses
    Rosetta space mission voted most important scientific breakthrough of 2014

    A memorable year for science – if not for mice

    The most important scientific breakthroughs of 2014
    Christmas cocktails to make you merry: From eggnog to Brown Betty and Rum Bumpo

    Christmas cocktails to make you merry

    Mulled wine is an essential seasonal treat. But now drinkers are rediscovering other traditional festive tipples. Angela Clutton raises a glass to Christmas cocktails
    5 best activity trackers

    Fitness technology: 5 best activity trackers

    Up the ante in your regimen and change the habits of a lifetime with this wearable tech
    Paul Scholes column: It's a little-known fact, but I have played one of the seven dwarves

    Paul Scholes column

    It's a little-known fact, but I have played one of the seven dwarves
    Fifa's travelling circus once again steals limelight from real stars

    Fifa's travelling circus once again steals limelight from real stars

    Club World Cup kicked into the long grass by the continued farce surrounding Blatter, Garcia, Russia and Qatar
    Frank Warren column: 2014 – boxing is back and winning new fans

    Frank Warren: Boxing is back and winning new fans

    2014 proves it's now one of sport's biggest hitters again
    Jeb Bush vs Hillary Clinton: The power dynamics of the two first families

    Jeb Bush vs Hillary Clinton

    Karen Tumulty explores the power dynamics of the two first families
    Stockholm is rivalling Silicon Valley with a hotbed of technology start-ups

    Stockholm is rivalling Silicon Valley

    The Swedish capital is home to two of the most popular video games in the world, as well as thousands of technology start-ups worth hundreds of millions of pounds – and it's all happened since 2009
    Did Japanese workers really get their symbols mixed up and display Santa on a crucifix?

    Crucified Santa: Urban myth refuses to die

    The story goes that Japanese store workers created a life-size effigy of a smiling "Father Kurisumasu" attached to a facsimile of Our Lord's final instrument of torture