“These patients were not simply numbers: they were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives.”
Those words from the preliminary enquiry findings of the Francis Inquiry into 400 deaths (perhaps more) at Mid Staffordshire Foundation Trust between 2005 and 2009 are as true now as when Robert Francis wrote them in February this year. So why has Mr Robert Francis QC chairing the expanded current inquiry chosen to focus on commissioning and related supervisory and regulatory processes in order to find out why problems leading to these deaths were not acted upon sooner. Mr Francis said: “This inquiry is not the forum in which professionals responsible at the front line for such care can be brought to account.”
No one wants a witch-hunt and the Francis enquiry is not a trial – so “bringing to account” is misleading language for Mr Francis to use. Real people were involved. We know who the patients were who got bad care – the relatives have told us – so why not open the enquiry process to the people from the care giving side and let them tell their stories?
Focus both on process and on individual actions
Mr Francis may be underestimating the public’s expectation of his enquiry and the overriding importance of the public interest in finding out what actually happened at Stafford Hospital. It could happen elsewhere unless governance processes (including but not restricted to commissioning) and individual clinical behaviour are drastically improved. We cannot understand governance failings without understanding failings in clinical practice and how their interaction in this instance created a culture in which failure could continue and people who were trying to do the right thing were thwarted.
There is an argument, of course, that long and drawn out enquiries, whatever their rules of engagement, are not contributing either to patients or families achieving satisfaction or to our knowledge of the causes of failure. “If they do not know by now what the causes of failure are, they never will” is a persuasive and intuitive conclusion. But it may also be premature. Without understanding exactly what went wrong (including when staff did things badly or tried to do them well) it is going to be very difficult for any recommendations to be made for the future which fully take account of the complexity of systems which rely on many individuals doing the right thing. It is in the public interest for information about failure to be out in the open.
Openness is also empathic – with the relatives and (by proxy) the dead patients and the staff – the good ones and there are plenty – who want to hear the full story. That is what the enquiry must address. It is not about assigning guilt and meting out punishments.
The focus should be both on process and on individuals. Why? Because process in the NHS is basically about how people work together. And process fails when it does not support the people who are trying to apply it. People may also fail all by themselves even if they have the best processes in the world to help them. So it is not “either/or” but a mixture of both that needs to be examined. And that is why an intuitive conclusion at this stage is insufficient.
Does no right of response equal “gagging”?
If I were a member of staff at that hospital, I would want to tell my story. I would not want, in effect, to be gagged. Individual staff have a right to argue in mitigation if they can and wish to. If we don’t see or hear from staff, the current Francis enquiry will be a charade and the public interest will not be served. Worse than that, the relatives will be frustrated and humiliated by a bureaucratic process and their anger will simply drive them on to seek resolution in some other way. Leaving any possible disciplinary action to a referral to the professional regulatory bodies after the current enquiry concludes is, simply, a denial of natural justice to everyone concerned.
Mr Francis justifies his position thus: “If I were to allow the identification of nurses and doctors and others who stand accused of providing poor care, they would stand accused in a public forum of serious complaints under the cloak of absolute privilege from defamation proceedings and be unable effectively to make a response. This is unfair to them, not helpful to the inquiry process and deflects from my central task. Fairness would, or might, require giving the individuals a right of response.”
That is precisely the point – giving them a right of response. So it is hard to understand why he doubts that a right of response could be given at his own the enquiry. He’s the chairman after all so he should be able to ensure this. To conclude that “there would be a real risk to their reputations and, where still employed by the trust, to the workings of the trust” is gagging and puts a permanent cloud of doubt over the reputations of every staff member concerned. This cannot be fair to them.
What we all want: an open, transparent and safe NHS
The local campaigning group “Cure the NHS” whose persistent efforts largely exposed the scandal at Stafford Hospital has argued against the anonymity order because it undermines the main purpose of the enquiry – which is to find out what actually happened so that we can learn from these shocking events. They know that truth is going to be very unpleasant, but it must be aired in an open and transparent enquiry. Names and faces matter: we are not dealing with “persons unknown” here.
It wasn’t just commissioning that failed at Stafford Hospital because that is just part of a bigger governance process. It was people who individually and collectively failed in their professional duties to provide safe, effective care. Safe and effective medical and nursing care predates commissioning and will survive long after it is a memory.
Mr Lansley is on record as saying that an open, transparent NHS is a safer NHS. We strongly agree. The public must be helped to understand how these events could happen so a recurrence can be prevented there and elsewhere. Knowledge and understanding are the first steps to meaningful public engagement, moving from passive victim of the health care system to active partner. Mr Francis and his enquiry team must allow names and faces to be put on events and then proceed in a fair and open way until the full and complex story is known.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations.