The Mid Staffordshire Foundation Trust public inquiry report has recommended there should be a series of new laws requiring all NHS staff and directors to be open and honest when mistakes happen.
This would include a new power for the Care Quality Commission to prosecute organisations and individuals who break the rules.
In his long awaited report, which makes a total of 290 recommendations, Robert Francis QC has called for a statutory duty of candour to be imposed on NHS directors to be “truthful” with information they give to healthcare regulators.
He has also called for a change in the law to impose a duty of candour on all doctors, nurses and registered professionals to admit mistakes which have caused “death or serious injury” to their employer as soon as possible.
All healthcare providers should also be required by law to inform the patient or relatives of the mistake and provide information to them.
Robert Francis QC has also recommended a new criminal offence should be created where any healthcare worker who knowingly obstructs others, provides misleading information to patients or families, or makes a dishonest statement to a commissioner or regulator could be prosecuted.
Mr Francis said the Care Quality Commission should be given the power to police this duty of candour and prosecute the most serious cases.
In his executive summary, Mr Francis said: “Stafford was not an event of such rarity or improbability that it would be safe to assume that it has not been and will not be repeated,” he said.
“The extent of the failure of the system shown in this report suggest that a fundamental culture change is needed. That does not require root and branch reorganisation – the system has had many of those – but it requires changes which can largely be implemented within the system that has now been created by the new reforms.
“I hope that the recommendations…put patients where they are entitled to be – the first and foremost consideration of the system and everyone who works in it.”