Lessons for healthcare from the Mid Staffordshire Inquiry – 5 th December 2013

1. Lessons for healthcare from the Mid Staffordshire Inquiry – 5th December 2013 Peter Watkin Jones Partner, Eversheds LLP Solicitor to the Mid Staffordshire NHS Foundation Trust Public Inquiry

2. A watershed moment • The Francis Reports – Putting the Patient first • The Berwick Report – A learning culture • The Clwyd & Hart Report • The Cavendish Report

3. The Keogh report: - Not confined to Stafford - No one operates in geographical, professional or academic isolation • Government response to Francis: “While the remit of the Francis Inquiry was explicitly limited to the NHS, the Inquiry’s recommendations resonate across the health and care system as a whole” • “Poor care can occur anywhere across the health and social care system”

4. The staff voice not heard If you are in that environment for long enough, what happens is you either become immune to the sound of pain or you walk away. You cannot feel people’s pain, you cannot continue to want to do the best you possibly can when the system says no to you. A doctor who started in A&E in October 2007

5. The staff voice not heard • “We have got to go on doing our job because we have patients who need operations; we will have to mend and make do. Which is the Stafford way”. • Keogh – “organisations trapped in mediocrity”. • Disengagement – “not my problem to solve”

6. A negative non-listening culture?

7. Those who could/should have picked up the signs of the need to protect the public • GPs • Professionals and their regulators • The Board – executive • The Board – non executive • The Commissioners • The Regulators • Healthcare Commission/Care Quality Commission • Monitor • Health & Safety Executive • The Department of Health/SHA

8. Recommendations Categories 1-5 – all to achieve culture change • Openness, transparency and candour • Fundamental standards • Accurate, useful and relevant information • Compassionate, caring, committed nursing • Strong patient centred healthcare leadership

9. The Government response – some major headlines • 281 recommendations adopted in whole or in part • “Traditionally, the response of the Government and of the central organisations of the NHS to failure in care has been to acknowledge the individual failing and then emphasise the very large number of positive experiences and excellent outcomes that people experience every day in the NHS” • Assurance first, ask questions later

10. Category 1Openness, transparency & candour • Openness: enabling concerns and complaints to be raised freely and fearlessly, and questions to be answered fully and truthfully • Transparency: making accurate and useful information about performance and outcomes available to staff, patients, public and regulators • Candour: informing patients where they have or may have been avoidably harmed by healthcare service whether or not asked

11. Candour • Statutory obligation • Individual professionals under a duty to inform the organisation • healthcare provider organisation under a duty to inform patient, whether or not asked (174) • Statutory sanction • Wilful obstruction of these duties should be a criminal offence • Deliberate deception of patients in performing duty should be a criminal offence

12. Category 1Openness, transparency and candour – Government response • Statutory duty of candour to report mistakes that caused death or serious injury; possibly moderate harm (Dalton and Williams Consultation) from 2014 on every provider registered with CQC • Candour on care failings a pre-requisite to CQC registration • The CQC can prosecute providers in breach of the fundamental standards • Individual director can then be prosecuted if offence committed with their consent, connivance or through neglect • Contractual duty of candour – NHS Constitution (2013) • Professional duty of candour – when mistakes occur that could have led to death/serious injury/actual harm – “near misses”

13. Openness, transparency and candour – Government response • Separate Criminal Offence (CPS) for providers to supply false or misleading information in complying with a legal obligation • “Controlling mind” applies again • Separate Criminal Offence where organisations or individuals are guilty of wilful or reckless neglect or mistreatment or patients • Trust should reimburse NHSLA compensation in whole/part if not been open

14. Category 2Fundamental standards • What the public see as absolutely essential • What the professions accept can be achieved • Prescribed medication given • Food and water to sustain life and well being supplied and any needed help given • Patients and equipment kept clean • Assistance where required provided to go to the lavatory • Consent for treatment obtained

15. Category 2Fundamental standards – Government response • CQC to create fundamental standards • Generalist inspection has run its course • Inspection to involve experts and the public • A failure regime allowing CQC to close a service or ward without notice • Staffing levels and fitness of directors will form part of inspection selection criteria • NICE to report by summer 2014 • Boards to publish actual and planned staffing for each shift monthly and review every 6 months • Details of skill mix

16. Category 3ACCURATE USEFUL RELEVANT INFORMATION • Individual and collective responsibility to devise performance measures • Patient, public, commissioners and regulators should have access to effective comparative performance information for all clinical activity • Improve core information systems

17. Category 3Accurate useful and relevant information – Government response • CQC and NHS England with others to make patient safety data accessible • Health & Social Care Information Centre to be the focal point • Information on staffing, pressure sores, falls and other key indicators • Quarterly publication of never events • Name of consultant and nurse responsible for care above bed • Clinical outcomes by consultant being published in 10 specialities • Data on friends and family test to be published (mental health setting - December 2014) • Quarterly reports on complaints data and lessons learned • Spring 2015 – every patient can see their records online, and book appointment

18. Category 4COMPASSIONATE CARING COMMITTED NURSING • Aptitude assessment on entry • Hands on experience a prescribed requirement • Named nurse [and doctor] responsible for each patient • Code of conduct and common training standards for healthcare workers • Registration requirement for healthcare workers plus power to disqualify/share info re concerns • Reward good practice; recognise special status of providing care for the elderly • Keogh – avoid over reliance on unregistered support staff and temporary staff • Publish staffing levels at least every 6 months

19. Category 4Compassionate Nursing – Government response • Care Certificate (2 levels) – Camilla Cavendish • Pilots of 1 year pre degree experience • Develop appraisal and development programmes • Develop older person’s nurse post graduate training qualification • Staffing levels/skill mix

20. Category 5Patient Centred Leadership • Cultural “buy in” • Common code of ethics, standards and conduct for all senior managers and NHS leaders • Liable for disqualification unless fit and proper person • Leadership staff college – accreditation scheme • Mentoring

21. Category 5Patient Centred Leadership – Government response • Providers to refer staff to Disclosure and Barring Service if has harmed, or poses a risk of harm • Fit and proper person test to also act as barring scheme for board level by CQC • Applies to public, private and voluntary sectors • Appraisals; performance management; provider ratings linked to performance • Fast track leadership programme; a drive to attract clinicians

22. Conclusion • Secretary of State: “We need to face up to the hard truths” • “The public must be told the reality of NHS performance….without political or system interference” • Statement of common purpose “We will listen” • Secretary of State for Health: “We need to hear the patient, seeing everything from their perspective, not the system’s interests”