Report Of The Mid Staffordshire Nhs Foundation Trust Public Inquiry

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.

This is a Government response to (HCP 898, (ISBN 9780102981469)), the inquiry into the Mid Staffordshire NHS Foundation Trust on the failure of care. It sets out a collective commitment and a plan of action to eradicate harm and aspire to excellence and to ensure that patients are "the first and foremost consideration of the system and everyone who works in it" and so restore the NHS to its core humanitarian values. This response sets out a five point plan, under the following headings: (A) Preventing problems; (B) Detecting problems quickly; (C) Taking action promptly; (D) Ensuring robust accountablity; (E) Ensuring staff are trained and motivated.

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.

If every system is perfectly designed to get the results it gets, what is wrong with the design of the systems that govern Britain? And how have they resulted in failures in housing, privatisation, outsourcing, education and healthcare? In How Did Britain Come to This? Gwyn Bevan examines a century of varieties of systemic failures in the British state. The book begins and ends by showing how systems of governance explain scandals in NHS hospitals, and the failures and successes of the UK and Germany in responding to Covid-19 before and after vaccines became available. The book compares geographical fault lines and inequalities in Britain with those that have developed in other European countries and argues that the causes of Britain’s entrenched inequalities are consequences of shifts in systems of governance over the past century. Clement Attlee’s postwar government aimed to remedy the failings of the prewar minimal state, while Margaret Thatcher’s governments in the 1980s in turn sought to remedy the failings of Attlee’s planned state by developing the marketised state, which morphed into the financialised state we see today. This analysis highlights the urgent need for a new political settlement of an enabling state that tackles current systemic weaknesses from market failures and over-centralisation. This book offers an accessible, analytic account of government failures of the past century, and is essential reading for anyone who wants to make an informed contribution to what an innovative, capable state might look like in a post-pandemic world.

On cover and title page: House, committees of the whole House, general committees and select committees. On title page: Returns to orders of the House of Commons dated 14 May 2013 (the Chairman of Ways and Means)

Medical Negligence in Victorian Britain is the first detailed exploration of the hundreds of charges of neglect against doctors who were contracted to the 'new' poor law after the Poor Law Amendment Act of 1834. The author moves beyond the hyperbole of Victorian public 'scandal' to use medical negligence as a prism through which to view hidden aspects of poor law doctors and their patients. This provides a uniquely grounded perspective, from the day-to-day experience of medical practice – for both doctor and patient – to the context of the medico-political, socio-legal and cultural processes that underpinned the social construction of negligence at this time. The result is a clearly enunciated description of what negligence meant to the Victorians and how they sought to define and deal with negligent care, moving the topic from the sidelines of English welfare history to the centre-stage role it played in Victorian society. Thematically and chronologically arranged in two parts, the book uses extensive new archival material with a particular focus on the official inquiries into neglect conducted by poor law inspectors. It offers a fresh perspective on the poor laws that has repercussions for wider histories of welfare, medicine and legal medicine.

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.

This book explores patient safety themes in developed, developing and transitioning countries. A foundation premise is the concept of ‘reverse innovation’ as mutual learning from the chapters challenges traditional assumptions about the construction and location of knowledge. This edited collection can be seen to facilitate global learning. This book will, hopefully, form a bridge for those countries seeking to enhance their patient safety policies. Contributors to this book challenge many supposed generalisations about human societies, including consideration of how medical care is mediated within those societies and how patient safety is assured or compromised. By introducing major theories from the developing world in the book, readers are encouraged to reflect on their impact on the patient safety and the health quality debate. The development of practical patient safety policies for wider use is also encouraged. The volume presents a ground-breaking perspective by exploring fundamental issues relating to patient safety through different academic disciplines. It develops the possibility of a new patient safety and health quality synthesis and discourse relevant to all concerned with patient safety and health quality in a global context.