The final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry was published today. The report can be viewed on the Inquiry’s website, to view click here.

Mid Staffordshire is a story of a hospital where hundreds of patients and their families suffered unnecessarily and of a regulatory and supervisory system that failed to identify the warning signs and prevent poor care from occurring and continuing.

Along with an in depth and comprehensive examination of what went wrong, the Chairman of the Inquiry, Robert Francis QC, has set out in his report 290 wide-ranging recommendations, which taken together are intended to develop a healthier culture in the NHS where every individual operating within the NHS has a personal responsibility to ensure that good practice is delivered to all, with the patient placed at the centre of the service.  The conclusions and recommendations in the report are predicted to change the culture and face of the NHS.

Eversheds has been involved from the outset, as solicitors to the Inquiry, with a team of around 30 lawyers, gathering the necessary evidence, and supporting and assisting the Chairman’s work.


On 9 June 2010, the then Secretary of State for Health, Andrew Lansley MP, announced a full public inquiry into the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire Foundation NHS Trust.

The Inquiry was established under the Inquiries Act 2005 and is chaired by Robert Francis QC.  Under the terms of reference for the Inquiry, Robert Francis is required to identify how, in the future, the NHS and the bodies which regulate it can ensure that failing and potentially failing hospitals or their services are identified as soon as is practicable and to make recommendations to the Secretary of State for Health based on the lessons learned from the events at Mid Staffordshire, building on the work of his earlier independent inquiry into the care provided by Mid Staffordshire hospital.

The purpose of the Inquiry was to discover how the authorities and bodies responsible for regulating, supervising and commissioning the NHS allowed the events at Mid Staffordshire to happen.

Evidence was gathered from around 350 witnesses, with over 1 million pages of evidence being considered and reviewed, over a period of one year, thereby enabling the Inquiry to conduct an in depth analysis of the English regulatory health system and the culture surrounding it, and allowing the Chairman to identify lessons to be learned and make pertinent recommendations for the future.

The Conclusions of the Report

The evidence before the Inquiry revealed, as set out in the findings of the final report, that the regulatory, supervisory and commissioning systems in place at the time failed on a spectacular basis and should have discovered the lack of care sooner.

The patient's voice was not heard, or it was not listened to through official channels.  The local medical community did not raise the alarm until it was too late.  The regulatory and supervisory bodies failed in their various tasks to hold the hospital to account and place patients at the centre of everything they did, and they were not equipped or resourced to enable such tasks to be carried out effectively.

So what is the solution? The report makes it clear that the answer is not wholesale structural reform. Instead, the key themes running through the Chairman’s recommendations focus on culture.

The report makes clear that there is a need for a wholesale change to the culture underpinning the NHS.  Whatever the system it will fail unless there is a proper culture that permeates from the top to the bottom, with safety and patients at the top of the list.  That is not the current culture.  The current culture emerging from evidence taken is one of doing the system's business; keeping bad news quiet; tolerating unacceptable performance; not sharing information; constant reorganisation with loss of continuity and loss of memory, predicated on the assumption that changing a system will cure its faults and shortcomings.

There is also a need for clarity. Regulators and all in the system need to understand their roles, and how they can contribute to the overwhelming number one priority - patient safety. It is recommended that Monitor's governance role be subsumed into the Care Quality Commission.

The report also recommends a need to instil zero tolerance of poor care at every level of the system, with fundamental standards of safety being policed by the healthcare regulator, and consequences following from any failure of those standards. Serious failures to comply should attract criminal sanction under new offences recommended by the report.

Underpinning all of this, it is recommended that the NHS must be open. It must be transparent, with honesty in reporting bad results as well as good.  There must be a duty of candour to patients and to the public, but also a duty for organisations to be open with their regulators and commissioners. Breaches of these duties are also recommended to be criminal offences.


There is no doubt that every worker in the NHS will be affected by the recommendations in the report.  And more than that, the outcome of this report and the implementation of its recommendations will be of interest to every member of the public, as patients or future patients of the NHS.

Every organisation at each level must work out how it will ensure that cultural change can be embraced and enacted by them. How should their training change? How should leaders best manifest their commitment to the new open and transparent culture? How will patients be listened to? How will training be redesigned? How will appraisals be conducted? How will be honesty and openness be encouraged? How will poor performance be identified, managed and tackled?

These are all questions that NHS organisations and personnel will have to consider if they are to avoid another Mid Staffs.