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
PROMOTED VIDEO
Life and Style
ebookNow available in paperback
ebooks
ebookPart of The Independent’s new eBook series The Great Composers
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

    Tradewind Recruitment: English Teacher

    Negotiable: Tradewind Recruitment: My client is an excellent, large partially ...

    Tradewind Recruitment: Science Teacher

    £90 - £140 per day: Tradewind Recruitment: I am currently working in partnersh...

    Tradewind Recruitment: Year 3 Primary Teacher

    £100 - £150 per day: Tradewind Recruitment: Year 3 Teacher Birmingham Jan 2015...

    Ashdown Group: Lead Web Developer (ASP.NET, C#) - City of London

    £45000 - £50000 per annum + Excellent benefits: Ashdown Group: Lead Web Develo...

    Day In a Page

    Isis hostage crisis: The prisoner swap has only one purpose for the militants - recognition its Islamic State exists and that foreign nations acknowledge its power

    Isis hostage crisis

    The prisoner swap has only one purpose for the militants - recognition its Islamic State exists and that foreign nations acknowledge its power, says Robert Fisk
    Missing salvage expert who found $50m of sunken treasure before disappearing, tracked down at last

    The runaway buccaneers and the ship full of gold

    Salvage expert Tommy Thompson found sunken treasure worth millions. Then he vanished... until now
    Homeless Veterans appeal: ‘If you’re hard on the world you are hard on yourself’

    Homeless Veterans appeal: ‘If you’re hard on the world you are hard on yourself’

    Maverick artist Grayson Perry backs our campaign
    Assisted Dying Bill: I want to be able to decide about my own death - I want to have control of my life

    Assisted Dying Bill: 'I want control of my life'

    This week the Assisted Dying Bill is debated in the Lords. Virginia Ironside, who has already made plans for her own self-deliverance, argues that it's time we allowed people a humane, compassionate death
    Move over, kale - cabbage is the new rising star

    Cabbage is king again

    Sophie Morris banishes thoughts of soggy school dinners and turns over a new leaf
    11 best winter skin treats

    Give your moisturiser a helping hand: 11 best winter skin treats

    Get an extra boost of nourishment from one of these hard-working products
    Paul Scholes column: The more Jose Mourinho attempts to influence match officials, the more they are likely to ignore him

    Paul Scholes column

    The more Jose Mourinho attempts to influence match officials, the more they are likely to ignore him
    Frank Warren column: No cigar, but pots of money: here come the Cubans

    Frank Warren's Ringside

    No cigar, but pots of money: here come the Cubans
    Isis hostage crisis: Militant group stands strong as its numerous enemies fail to find a common plan to defeat it

    Isis stands strong as its numerous enemies fail to find a common plan to defeat it

    The jihadis are being squeezed militarily and economically, but there is no sign of an implosion, says Patrick Cockburn
    Virtual reality thrusts viewers into the frontline of global events - and puts film-goers at the heart of the action

    Virtual reality: Seeing is believing

    Virtual reality thrusts viewers into the frontline of global events - and puts film-goers at the heart of the action
    Homeless Veterans appeal: MP says Coalition ‘not doing enough’

    Homeless Veterans appeal

    MP says Coalition ‘not doing enough’ to help
    Larry David, Steve Coogan and other comedians share stories of depression in new documentary

    Comedians share stories of depression

    The director of the new documentary, Kevin Pollak, tells Jessica Barrett how he got them to talk
    Has The Archers lost the plot with it's spicy storylines?

    Has The Archers lost the plot?

    A growing number of listeners are voicing their discontent over the rural soap's spicy storylines; so loudly that even the BBC's director-general seems worried, says Simon Kelner
    English Heritage adds 14 post-war office buildings to its protected lists

    14 office buildings added to protected lists

    Christopher Beanland explores the underrated appeal of these palaces of pen-pushing
    Human skull discovery in Israel proves humans lived side-by-side with Neanderthals

    Human skull discovery in Israel proves humans lived side-by-side with Neanderthals

    Scientists unearthed the cranial fragments from Manot Cave in West Galilee