The Francis Report(Mid Staffordshire Hospital) Karen Smith Head of Patient Safety and Clinical Effectiveness
At about 3.30am the phone goes. It was Roy, who said: “Dad, they have told me I have to fetch mum out.” “You’re joking!” I said. He told me that is how it is at Stafford … she had Alzheimers … I had no idea how I was going to get [my wife] home. Fortunately Roy managed to find some mates to help. No attention was given to the fact it was 3.30am in the morning or my situation – I had a quadruple bypass four years ago … I also did not know how I would get [her] out of the car when Roy arrived with [her] … We took the commode out to the car and then carried it back to the house with [her] on it. They had at least put a shawl around her shoulders, which is just as well given that she only had a nightie on … as Roy was settling her in the house … he discovered that the hospital had left the cannula in her. Fortunately, as he was a paramedic, he knew how to remove this safely
Warning Signs • Patient Stories • Mortality • Complaints • Staff concerns • Whistle-blowers • Governance issues • Finance • Staff reductions
It was when mum’s bed was being wheeled on to the … ward … and there was two nurses sort of guiding us into the room, and I just asked if mum could have her teatime medication, because it was now about half past 7. • And she said “You’re too late for the teatime medication. You should have been here at 4 o’clock”. • Q. So what happened about that medication? • She didn’t get that medication until the night medication, about 11 o’clock.
Francis noted 5 essential elements • A structure of clearly understood fundamental standards and measures of compliance. • Openness, transparency and candour throughout the system. • Improved support for compassionate caring and committed nursing • Strong and patient centred healthcare leadership. • Accurate, useful and relevant information.
When I arrived Gill was unconscious and on oxygen. There was a doctor and a nurse attending to her and the doctor said “I’m very sorry but Gill’s sugar is very high.” I said “Oh my gosh … she is in a hyperglycaemic coma” … It was apparent Gill had not been given insulin … As I stood away from the nurses desk … I heard the doctor ask the nurse “has Mrs. Astbury had any insulin today as there is nothing on the chart?” The nurse said “I don’t know I have only just come on”.
Recommendations for Commissioners overview • Commissioning for standards • Duty to require and monitor delivery of fundamental standards • Responsibility for requiring and monitoring delivery of enhanced standards • Preserving corporate memory • Resources for scrutiny • Expert support • Ensuring assessment and enforcement of fundamental standards through contracts • Relative position of commissioner and provider
Recommendations for Commissioners overview • Development of alternative sources of provision • Monitoring tools • Role of commissioners in complaints • Role of commissioners in provision of support for complainants • Public accountability of commissioners and public engagement • Commissioners need to be recognisable public bodies. • Intervention and sanctions for substandard or unsafe services • Commissioners should have contingency plans with regard to the protection of patients from harm.
Some of the people in there can’t even get out of bed; they can’t fill in their own menu. You would find the food tray was 3 foot away from the bed; they couldn’t get a drink. There was just nobody there. I remember a conversation with one of the senior nurses who told me that she was on her own and had 50 meals to serve. I’d have put an apron on myself and gone and helped, that is what you felt you wanted to do.
Local assurance mechanisms • Quality Review/Improvement Visiting Programme • Serious Incidents – reporting and learning • Health sub-group of Adult Safeguarding Board • Quality Accounts – review/scrutiny • Complaints system – monitoring and learning • Performance and Contract Monitoring • Francis Action Plan – CCG Governing Bodies
Did the healthcare assistant who brought her food make any attempt to help her? • She didn’t make any attempt at all. She didn’t even speak. There was not a word said when she put the tray down and when she took the tray away. • Q. So what did you do? • I just said ‘She hadn’t – she hasn’t eaten her food at all’. • And she just – she just walked out the door, and as she was going she said • ‘She never does’.
Transparency • What matters to patients? - Measure and report on it publicly • “I want to know what you know” • But: exposure of poorer performance, without action to address it, harms public confidence
Unhappily, the word “hindsight” occurs at least 123 times in the transcript of the oral hearings of the Inquiry report, and “benefit of hindsight” 378 times. It is easier to recognise what should have been done at the time now that the enormity of what was occurring in the Trust is better known.
The failure of the system to detect the deficiencies at the Trust and take effective action soon enough means that the public is unlikely to have confidence that “another Stafford” does not exist, in the absence of being convincingly persuaded that sufficient change has taken place. Stafford was not an event of such rarity or improbability that it would be safe to assume that it has not been and will not be repeated. The consequences for patients are such that it would be quite wrong to use a belief that it was unique or very rare to justify inaction.