Independent Inquiry Into Care Provided By Mid Staffordshire Nhs Foundation Trust January 2005 March 2009

Concerns about mortality and the standard of care provided at the Mid Staffordshire NHS Foundation Trust resulted in an investigation by the Healthcare Commission which published a highly critical report in March 2009, followed by two reviews commissioned by the Department of Health. These investigations gave rise to widespread public concern and a loss of confidence in the Trust, its services and management. This Inquiry was set up primarily to give those most affected by poor care an opportunity to tell their stories and to ensure that the lessons learned were fully taken into account in the rebuilding of confidence in the Trust. The evidence received about the patient experience covered many areas of basic nursing and medical care, communication and discharge management. The culture of the Trust was not conducive to providing good care for patients or providing a supportive working environment for staff due to: attitudes of patients and staff; bullying; target-driven priorities; disengagement from management; low staff morale; isolation from the wider NHS community; lack of openness; acceptance of poor standards of conduct; reliance on external assessments; denial. The report also looks at the management of significant issues - ward reconfiguration, finance, staff cuts - governance, staff review, the Board, mortality statistics and external organisations. Major themes identified by the Inquiry are: focus on process not outcomes; failure to listen to complaints; insufficient attention to maintenance of professional standards; lack of support for staff; failure to meet the challenge of care for the elderly; lack of transparency; disregard of the significance of mortality statistics.

This public inquiry report into serious failings in healthcare that took place at the Mid Staffordshire NHS Foundation Trust builds on the first independent report published in February 2010 (ISBN 9780102964394). It further examines the suffering of patients caused by failures by the Trust: there was a failure to listen to its patients and staff or ensure correction of deficiencies. There was also a failure to tackle the insidious negative culture involving poor standards and a disengagement from managerial and leadership responsibilities. These failures are in part a consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status at the cost of delivering acceptable care standards. Further, the checks and balances that operate within the NHS system should have prevented the serious systemic failure that developed at Mid Staffs. The system failed in its primary duty to protect patients and maintain confidence in the healthcare system. This report identifies numerous warning signs that could and should have alerted the system to problems developing at the Trust. It also sets out 290 recommendations grouped around: (i) putting the patient first; (ii) developing a set of fundamental standards, easily understood and accepted by patients; (iii) providing professionally endorsed and evidence-based means of compliance of standards that are understood and adopted by staff; (iv) ensuring openness, transparency and candour throughout system; (v) policing of these standards by the healthcare regulator; (vi) making all those who provide care for patients , properly accountable; (vii) enhancing recruitment, education, training and support of all key contributors to the provision of healthcare; (viii) developing and sharing ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and other stakeholders.

The author shows beyond question that neglectful care is a systemic blight, rather than mere local blemish, within our health services. He analyses the causes and factors involved, reveals the widespread denial and lack of accountability from those responsible, and spells out implications of this failure to care for the vulnerable with humanity.

This book explores how concerns can be raised about the NHS, why raising concerns hasn't always improved standards, and how a no-fault open culture approach could drive improvements. The book describes a wide range of mechanisms for raising concerns about the NHS, including complaints, the ombudsman, litigation, HSIB, and the major inquiries since 2000, across the various UK jurisdictions. The NHS approach is contextualised within the broader societal developments in dispute resolution, accountability, and regulation. The authors take a holistic view, and outline practical solutions for reforming how the NHS responds to problems. These should improve the situation for those raising concerns and for those working within the NHS, as well as providing cost savings. The no-fault approaches proposed in the book provide long-term sustainable solutions to systemic problems, which are particularly timely given the impact of the COVID-19 pandemic on the NHS. The book will be of interest to academics, researchers, ADR practitioners, practising lawyers, and policy makers.

This book presents the proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), held on August 26-30, 2018, in Florence, Italy. By highlighting the latest theories and models, as well as cutting-edge technologies and applications, and by combining findings from a range of disciplines including engineering, design, robotics, healthcare, management, computer science, human biology and behavioral science, it provides researchers and practitioners alike with a comprehensive, timely guide on human factors and ergonomics. It also offers an excellent source of innovative ideas to stimulate future discussions and developments aimed at applying knowledge and techniques to optimize system performance, while at the same time promoting the health, safety and wellbeing of individuals. The proceedings include papers from researchers and practitioners, scientists and physicians, institutional leaders, managers and policy makers that contribute to constructing the Human Factors and Ergonomics approach across a variety of methodologies, domains and productive sectors. This volume includes papers addressing Healthcare Ergonomics.

The relationship between spirituality and healthcare is historical, intellectual and practical, and it has now emerged as a significant field in health research, healthcare policy and clinical practice and training. Understanding health and wellbeing requires addressing spiritual and existential issues, and healthcare is therefore challenged to respond to the ways spirituality is experienced and expressed in illness, suffering, healing and loss. If healthcare has compassionate regard for the humanity of those it serves, it is faced with questions about how it understands and interprets spirituality, what resources it should make available and how these are organised, and the ways in which spirituality shapes and informs the purpose and practice of healthcare? These questions are the basis for this resource, which presents a coherent field of enquiry, discussion and debate that is interdisciplinary, international and vibrant. There is a growing corpus of articles in medical and healthcare journals on spirituality in addition to a wide range of literature, but there has been no attempt so far to publish a standard text on this subject. Spirituality in Healthcare is an authoritative reference on the subject providing unequalled coverage, critical depth and an integrated source of key topics. Divided into six sections including practice, research, policy and training, the project brings together international contributions from scholars in the field to provide a unique and stimulating resource.

This is an essential ‘theory’ textbook for the ODP degree and diploma and is the first to bring together the ‘non practical’ issues taught on the course.

Lessons from service and system failures describe how governance and leadership each play a pivotal role in high-quality, safe care. This title is also available as Open Access on Cambridge Core.