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Stafford Hospital inquiry looks at 'poor standards' Stafford Hospital inquiry to look at 'poor standards'
(40 minutes later)
An inquiry into avoidable deaths at Stafford Hospital will look at why the health care system tolerated "unacceptable care standards". An inquiry into avoidable deaths at Stafford Hospital will look at why the health care system tolerated a "terrible standard of service".
A 2009 report condemned conditions at the hospital, said to have caused hundreds of avoidable deaths.A 2009 report condemned conditions at the hospital, said to have caused hundreds of avoidable deaths.
The last government ordered a private investigation, but refused a wider public inquiry.The last government ordered a private investigation, but refused a wider public inquiry.
But in June the coalition government said the families of those who died deserved to know what went wrong.But in June the coalition government said the families of those who died deserved to know what went wrong.
Campaigners praisedCampaigners praised
The start of the inquiry was delayed after one of the relatives objected because family members and the media were in a different room from the inquiry chairman, Robert Francis QC, and his panel.The start of the inquiry was delayed after one of the relatives objected because family members and the media were in a different room from the inquiry chairman, Robert Francis QC, and his panel.
The Mid Staffordshire NHS Foundation Trust Public Inquiry is being held at the offices of Stafford Borough Council.The Mid Staffordshire NHS Foundation Trust Public Inquiry is being held at the offices of Stafford Borough Council.
It is the fifth inquiry into the higher than expected deaths at Stafford Hospital between 2005 and 2008.It is the fifth inquiry into the higher than expected deaths at Stafford Hospital between 2005 and 2008.
Mr Francis also chaired the fourth inquiry, which he criticised for its narrow remit.Mr Francis also chaired the fourth inquiry, which he criticised for its narrow remit.
In setting out the framework on Monday, Mr Francis said he would not revisit the harrowing cases of deceased patients brought to light in the fourth inquiry, which was held in private.In setting out the framework on Monday, Mr Francis said he would not revisit the harrowing cases of deceased patients brought to light in the fourth inquiry, which was held in private.
Instead he said he wanted to look at the structure of the NHS and the actions and inactions of management to see how the failings had come about and why they had remained undetected for so long.Instead he said he wanted to look at the structure of the NHS and the actions and inactions of management to see how the failings had come about and why they had remained undetected for so long.
He also paid tribute to the relatives and campaigners from groups such as Cure the NHS, which was set up to highlight problems at Stafford Hospital.He also paid tribute to the relatives and campaigners from groups such as Cure the NHS, which was set up to highlight problems at Stafford Hospital.
He said without their tenacity in calling for a full investigation, many of the findings would never have seen the light of day.He said without their tenacity in calling for a full investigation, many of the findings would never have seen the light of day.
He said everyone was here because of the "terrible standard of service inflicted on so many of the patients who went to Stafford Hospital and their families".He said everyone was here because of the "terrible standard of service inflicted on so many of the patients who went to Stafford Hospital and their families".
"Last year, in my first inquiry, I sat and listened to many stories of appalling care," he said."Last year, in my first inquiry, I sat and listened to many stories of appalling care," he said.
"As I did so, the question that went constantly through my mind were, why did none of the many organisations charged with the supervision and regulation of our hospital detect that something so serious was going on, and why was nothing done about it?""As I did so, the question that went constantly through my mind were, why did none of the many organisations charged with the supervision and regulation of our hospital detect that something so serious was going on, and why was nothing done about it?"
'Serious errors''Serious errors'
Tom Kark QC, leading counsel to the inquiry, the purpose of the inquiry was to focus not on what went wrong but how it was allowed to go on for so long.Tom Kark QC, leading counsel to the inquiry, the purpose of the inquiry was to focus not on what went wrong but how it was allowed to go on for so long.
He said: "Why did no-one act to correct the serious errors that were undoubtedly taking place?He said: "Why did no-one act to correct the serious errors that were undoubtedly taking place?
"Why did the health care system as a whole tolerate what were clearly unacceptable standards of care?"Why did the health care system as a whole tolerate what were clearly unacceptable standards of care?
"Why did the those who should have been in the right position to take steps not do so? ""Why did the those who should have been in the right position to take steps not do so? "
He said he had sought to ensure that every relevant nook and cranny of the health service was explored and that his team would strive not to leave a pebble unturned which might "reveal material of interest".He said he had sought to ensure that every relevant nook and cranny of the health service was explored and that his team would strive not to leave a pebble unturned which might "reveal material of interest".
Hoping for answersHoping for answers
Julie Bailey, who set up Cure the NHS, said: "This will get to the truth. We really believe this will be a full examination of what went wrong, not just at the hospital but with the regulatory bodies."Julie Bailey, who set up Cure the NHS, said: "This will get to the truth. We really believe this will be a full examination of what went wrong, not just at the hospital but with the regulatory bodies."
The public inquiry will look beyond the walls of Stafford Hospital at the way the NHS is managed.The public inquiry will look beyond the walls of Stafford Hospital at the way the NHS is managed.
Amongst the million pages of documents there are submissions from doctors, staff and patients from other parts of the country recording similar experiences. Among the million pages of documents there are submissions from doctors, staff and patients from other parts of the country recording similar experiences.
Key to the inquiry will be the role of the statutory regulators.Key to the inquiry will be the role of the statutory regulators.
Monitor gave the hospital a clean bill of health and made it a foundation trust a month before the Healthcare Commission began its first investigation.Monitor gave the hospital a clean bill of health and made it a foundation trust a month before the Healthcare Commission began its first investigation.
Were The public inquiry will look beyond the walls of Stafford Hospital at the way the NHS is managed. The public inquiry will look beyond the walls of Stafford Hospital at the way the NHS is managed.
Amongst the million pages of documents there are submissions from doctors, staff and patients from other parts of the country recording similar experiences. Key to the inquiry will be the role they played in talking to each other?
Key to the inquiry will be the role they talking to each other?
Huge reputations are at stake; David Nicholson, now head of the entire NHS, was in charge in this region in 2005.Huge reputations are at stake; David Nicholson, now head of the entire NHS, was in charge in this region in 2005.
The current chief executive of the Care Quality Commission, Cynthia Bower, took over as head of West Midlands Strategic Health Authority, with responsibility for measuring quality and safety, from 2006 until 2008.The current chief executive of the Care Quality Commission, Cynthia Bower, took over as head of West Midlands Strategic Health Authority, with responsibility for measuring quality and safety, from 2006 until 2008.
Ultimately the inquiry's recommendations should change the way safety in our hospitals is monitored.Ultimately the inquiry's recommendations should change the way safety in our hospitals is monitored.
She said the inquiry should find out how much the 50 or so health regulators had known about the problems at Stafford Hospital.She said the inquiry should find out how much the 50 or so health regulators had known about the problems at Stafford Hospital.
"We believe that if they had done something about it when we first reported concerns, it would have saved many, many lives within this community.""We believe that if they had done something about it when we first reported concerns, it would have saved many, many lives within this community."
Problems at Stafford Hospital, run by the Mid Staffordshire NHS Trust, were first exposed by an NHS regulator in March 2009.Problems at Stafford Hospital, run by the Mid Staffordshire NHS Trust, were first exposed by an NHS regulator in March 2009.
The Healthcare Commission said there had been hundreds more deaths than there should have been between 2005 and 2008.The Healthcare Commission said there had been hundreds more deaths than there should have been between 2005 and 2008.
It listed a catalogue of failings, including cases where untrained accident and emergency receptionists had assessed emergency cases.It listed a catalogue of failings, including cases where untrained accident and emergency receptionists had assessed emergency cases.
The Labour government then started several investigations.The Labour government then started several investigations.
Catalogue of failingsCatalogue of failings
These included an independent inquiry led by Mr Francis, but it was held in private and did not have the power to compel witnesses to give evidence.These included an independent inquiry led by Mr Francis, but it was held in private and did not have the power to compel witnesses to give evidence.
When it reported in February it said the trust had been driven by targets and cost-cutting.When it reported in February it said the trust had been driven by targets and cost-cutting.
Managers had been focused on winning elite foundation trust status during the problem years.Managers had been focused on winning elite foundation trust status during the problem years.
But campaigners said the failings went far wider than the hospital itself, and the broader NHS and regulators should have realised there were problems and stepped in.But campaigners said the failings went far wider than the hospital itself, and the broader NHS and regulators should have realised there were problems and stepped in.
They demanded a full public inquiry with stronger legal powers.They demanded a full public inquiry with stronger legal powers.
In June, Health Secretary Andrew Lansley announced Mr Francis would continue the work he had already done on investigating the hospital by leading an inquiry.In June, Health Secretary Andrew Lansley announced Mr Francis would continue the work he had already done on investigating the hospital by leading an inquiry.
The inquiry will consider more than a million pages of evidence and will hear from dozens of witnesses.The inquiry will consider more than a million pages of evidence and will hear from dozens of witnesses.
Stafford Hospital management have said they have been working hard to improve patient care over the past 18 months.Stafford Hospital management have said they have been working hard to improve patient care over the past 18 months.
The new chief executive, Anthony Sumara, said they had taken on 140 more nurses, improved training, and changed procedures in the areas which had problems.The new chief executive, Anthony Sumara, said they had taken on 140 more nurses, improved training, and changed procedures in the areas which had problems.
He said he worried the impending reorganisation of the NHS and a tougher financial climate could provide the ingredients for similar problems to be repeated.He said he worried the impending reorganisation of the NHS and a tougher financial climate could provide the ingredients for similar problems to be repeated.
"We need to make sure we don't take our eye off the ball again," he warned."We need to make sure we don't take our eye off the ball again," he warned.
Have you been affected by the issues raised in this story? You can send us your stories using the form below:Have you been affected by the issues raised in this story? You can send us your stories using the form below: