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The Francis report and its aftermath. Conor Davidson. Compassion. Candour. Culture. Training. Leadership. Assurance. 2001. First Annual Dr Foster guide shows that Stafford Hospital had a higher than expected HSMR at 108. 2006.

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The Francis report and its aftermath

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The Francis report and its aftermath

Conor Davidson








First Annual Dr Foster guide shows that Stafford Hospital had a higher than expected HSMR at 108.


Reports in the local press that hospital is in a ‘squalid state’ (after visit by Terence Deighton)


  • June

    • Monitor begins the review of the Stafford Trust application for foundation status.

  • July

    • Dr Foster Unit sends Trust a series of mortality alerts.

  • Oct

    • First Royal College of Surgeons Report.


  • Jan

    • 'Cure the NHS' campaign group set up

  • Feb

    • Trust granted foundation status

  • Mar

    • HCC launches investigation



  • Mar

    • Healthcare Commission report published

    • Chair and Chief Exec resign

  • July

    • Second Royal College of Surgeons report

    • Public enquiry (Francis I) announced by new sec of state Andy Burnham



  • Feb

    • Francis I published

  • May

    • Coalition Government take power

  • June

    • Andrew Lansley commissions Francis II

"an atmosphere of fear of adverse repercussions"

"forceful style of management"

"pressure to meet targets"

"systemic failure of the provision of good care"

"too few staff, or staff not sufficiently qualified to cope"

"incontinent patients left in degrading conditions"

"injury and loss of dignity, often in the final days of their lives"

"delayed diagnosis"

"constant strain of financial difficulties"

"isolation from the wider NHS community"

"lacked effective clinical governance"


  • February

    • Francis report published

  • July

    • Keogh report investigating 14 outlier trusts published

  • August

    • Berwick NHS safety review published

  • October

    • Ann Clwyd review of NHS complaints system published

  • November

    • official government response to Francis report


  • At Stafford:

    • Soiled patients unattended

    • Call bells not answered

    • Patients being left without food and water

    • Extremely poor hygiene

    • Medication not administered properly

    • Lack of adequate heating

    • Failure to notice or respond to deteriorating conditions

    • Failure to listen to, take seriously and respond to concerns of relatives



Core values and fundamental standards**Aptitude test* Nurse training include 'at least 3 months' hands on care**Named nurses for patients**Regulation of Healthcare Support WorkersConsider creating role of registered older people's nurse*NICE to recommend staffing levels** (but note Keogh on reported vs actual staffing levels)


At Stafford:

Financial problems since 2003/04 Bullying management cultureBoard focused on achieving foundation trust statusIll thought-through staff cuts and service reconfigurationsDysfunctional consultant body



'Fit & Proper' person test for directors**Leadership college*System of accreditation/training for leadership posts*DoH should do impact assessments before any structural change of the healthcare system*


  • Openness – enabling concerns and complaints to be raised freely without fear and questions asked to be answered.

  • Transparency – allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators.

  • Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of

    whether a complaint has been made or a question asked about it.


  • At Mid Staffs:

    Disregarded criticismIneffectual complaints systemIsolated from wider NHSNo support for whistleblowersHigh HSMR blamed on coding errorFalsified records in A&E



More effective NHS complaints system**Statutory 'duty of candour' - to patients, public and regulators*Gagging clauses should be banned**Regulators should share information**Common information practices**Real time effective accessible data**


At Mid Staffs:

Poorly developed audit/clinical governance systemsBoard unaware of situation on the groundIgnoring indicators of poor performanceFailure of regulatory system

“The current NHS regulatory system is bewildering in its complexity”-Berwick report



Fundamental/enhanced standards*Clear metrics on quality** (Note Keogh on mortality ratios)

Fundamental standards should be rigorously enforced and to cause death or serious harm to a patient by noncompliance should be criminal offence**Single regulatorBeefed up commissioners*Note role of medical training in assurance


At Stafford:

Early warning signs - shabby & dirty environment, unsmiling staff who were distracted by mobile phones, didn't answer buzzers promptly, didn't pick up litterIsolated 'timewarp'Toleration of mediocrity'Keep your head down'BullyingIsolated 'Systems business' put over patients business



All of them!Focus on 'culture of caring''Cultural barometer'Vague points about values, teamwork, post discharge careFrustration at political interference in NHSSchwarz roundsCan cultural change be achieved through top down recommendations?

“In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.”

-Berwick report


  • Junior doctors in Stafford A&E and MAU (‘Beirut’) silenced

  • Lack of value and support being given to frontline clinicians, particularly junior nurses and doctors…’their energy must be tapped not sapped’

  • Five of Keogh organisations having training monitored by GMC

  • Deanery to visit local providers & report back to GMC

  • Medical students & trainees to be surveyed

  • All overseas doctors (inc EU nationals) need English language proficiency

The aftermath…

Run out of town

 Placing the quality of patient care, especially patient safety, above all other aims.

 Engaging, empowering, and hearing patients and carers throughout the entire system and at all times.

 Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.

Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.

  • Berwick report

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