Shaun Lintern charts the sequence of events that led to the public inquiry into the well-publicised care failings at Mid Staffordshire Foundation Trust
- March 1999 – Royal College of Nursing general secretary Christine Hancock criticises Stafford Hospital for cuts to frontline nurses
In a speech to the RCN conference in Harrogate in March 1999 she said hospital trusts were trying to save money by employing fewer senior nurses and weakening the skill mix ratio of qualified to unqualified staff.
The RCN had obtained internal plans that explored the option of reducing the level of senior nurses at Mid Staffordshire General Hospital. The plans were designed to re-organise the hospital wards into floors with patients no longer grouped by their condition or operation.
A spokesman for the hospital at the time dismissed her comments as “absolute nonsense”. But the re-organisation went ahead later and, along with staff reductions, led to a skill mix ratio of qualified to unqualified staff of 40:60.
- August 2001 – The Stafford Primary Care Group wrote a critical report of the management and leadership at Mid Staffordshire General Hospital
The group wanted the then chief executive and management removed
One of its members William Price, who would later become the chief executive of the South Staffordshire Primary Care Trust, told the public inquiry: “Our view was that the leadership at Mid Staffs hospitals was not competent, in our view, to carry out the functions that we would expect them to carry out.”
Mr Price said the problems had the “potential” to “impact on patient care”.
Despite the recommendations, the trust’s chief executive remained in post until 2005.
Mr Price later apologised for not doing more to assess the quality of patient care in his role as PCT chief executive.
- January 2002 – Commission for Health Improvement publishes a highly critical report on Mid Staffordshire NHS Trust, describing a lack of governance, poor culture and some staff under “constant pressure”
In 2002 the Commission for Health Improvement – a forerunner of the Healthcare Commission and Care Quality Commission – revealed a damning report into the governance of Mid Staffordshire Hospital.
It raised doubts about the hospital management and shortfalls in nurse staffing which could impact on patient care. The report said: “Throughout the review CHI received reports of nurse staffing shortfalls, which were perceived to directly influence the ability to provide quality care.”
It made a series of recommendations including a review of skill mix and dependency to ensure staff were deployed correctly. Despite concerns in the CHI report, action had still not been taken in 2004.
- May 2003 – Peer review report into care for critically ill and critically injured children raised serious concerns about the accident and emergency department at Stafford Hospital
The report identified there was no triage for children who arrived by their own transport in A&E and a lack of staff in the department.
It also highlighted a lack of training among medical staff and some of the nurses with ineffective systems to give the best care to children. Equipment was found not to meet standards and staff also expressed their concern about a lack of feedback from managers.
- July 2004 – Mid Staffordshire NHS Trust receives a zero star rating from the Healthcare Commission after having a three start rating a year earlier
- April 2005 – Toni Brisby is appointed chair of Mid Staffordshire NHS Trust
A few months after Mr Brisby’s appointment, chief executive David O’Neill leaves on secondment to another trust, but never returns. Martin Yeates is appointed interim chief executive and later takes on the role permanently.
- May 2005 – Stafford Hospital nurse Eva Clark dies after taking an overdose of anti-depressants. She had complained of bullying by a senior colleague
An inquest into her death was told the 49-year-old mother of five had been struggling to cope in her job at the hospital, and had complained to a “buddy” that a senior nurse colleague had been bullying her.
The ward manager at the time told the inquest the bullying concerns had not been passed on to her and denied there had been any harassment.
- August 2005 – David Nicholson, then chief executive of the Black Country Strategic Health Authority, takes on chief executive responsibilities for the Shropshire and Staffordshire SHA
- September 2005 – Martin Yeates is appointed chief executive of Mid Staffordshire Trust
Mr Yeates later told the Francis public inquiry he recognised at the time that “governance simply did not exist in a corporate or clinical sense”. Mid Staffordshire was his first post as a hospital trust chief executive
- March 2006 – Mid Staffordshire NHS Trust announces plans to axe 150 jobs in order to save £10m
As the trust looked to apply for foundation trust status, new chief executive Martin Yeates said 150 jobs had to be lost to save £10m.
This would ensure the trust would be sustainable, he claimed at the time. The trust also instigated a ban on the use of expensive agency staff. Around 150 posts were also left vacant at the trust, a third of which were clinical positions.
- May 2006 – Peer review of critical children’s services and A&E department raises serious safety concerns
The peer review report highlighted the same concerns as an earlier review in 2002.
It described A&E as being “vulnerable” and warned there was “insufficient senior medical cover in A&E”, with two consultants and an associate specialist working a one-in-three rota.
The report also found “insufficient nursing staff”, with no nurse available to triage patients.
- November 2005 – Government reduces the criteria for NHS trusts to apply for foundation trust status – from those with a “three star” rating from the Healthcare Commission to those with a “two star” rating
The checks for attaining foundation trust status at that time focussed primarily on finance and not quality of care.
- January 2006 – Mid Staffordshire NHS Trust is told it is at least two years away from applying for foundation trust status, following a meeting with its strategic health authority
Seven months later its FT application was approved by then health minister Andy Burnham. However, civil servants at the Department of Health believed the trust was “borderline”.
A committee of DH officials were told the trust’s bid “adds up to a less than convincing case that makes the application difficult to support”. But these concerns were not expressed to Mr Burnham.
- June 2006 – Cynthia Bower becomes chief executive of new NHS West Midlands SHA and David Nicholson appointed chief executive of NHS London SHA
- August 2006 – Consultant Physician Dr Peter Daggett writes to managers expressing fears over nursing shortages in Emergency Assessment Unit
He said: “It is self-evident there are not enough nurses and those few that are available are run ragged.”
Dr Daggett repeatedly raised concerns about care in the hospital since 2001 but he told the public inquiry he was “met with a wall of silence”.
He admitted to the inquiry he never considered raising his concerns outside the hospital and did not know the Healthcare Commission regulator existed.
- October 2006 – Primary care trusts merge in a major reorganisation of the NHS across the country, as do strategic health authorities
- April 2007 – Dr Foster Hospital Guide is published and highlights Mid Staffordshire NHS Trust as having a hospital standardised mortality rate (HSMR) of 127
This is 27% more deaths than were expected. Despite the high mortality rate, NHS West Midlands supported the trusts foundation trust application and made no mention of the death rates in its documentation to the Department of Health.
The trust maintained the problem was to do with how patient deaths were coded. The SHA commissioned a study by the University of Birmingham into the methodology behind the Dr Foster data, which the earlier independent inquiry concluded was an attempt to discredit the Dr Foster data.
- June 2007 – Trust receives support from health minister Andy Burnham to have its foundation trust bid decided by Monitor
Mr Burnham told the public inquiry he believed this would be an “intensive and rigorous” assessment. But he admitted the reality had been “180 degrees away from what my understanding was”.
- 2007 – Mortality alerts for a number of conditions begin to alert the Healthcare Commission to concerns at the trust
- October 2007 – Dr Chris Turner, an emergency medicine trainee, begins work at Stafford A&E and later describes the department as “an absolute disaster”
He complained of a bullying culture and harassment of staff to meet targets, which put patients at risk. With not enough staff, Dr Turner said the department had “no vision of what ‘good’ looked like”.
He said: “There were not enough nurses; those who remained were demoralised. They had no senior nurse to unite and lead them. They were threatened on a near daily basis that they would lose their jobs if they did not get patients through the department within the four hour target.”
He added: “The effect was that the Emergency Department contained significant numbers of patients in distress and, as a department, we were immune to the sound of pain.”
- November 8, 2007 – Bella Bailey, aged 86, dies at Stafford Hospital
Her daughter Julie Bailey maintained a bedside vigil after witnessing poor care of other patients. She writes a letter to local newspapers asking if others have suffered similar problems. She is overwhelmed by the response of other families expressing concerns.
- December 2007 – Cure the NHS action group, led by Julie Bailey, is formed after a public meeting
The group begins to speak out about poor care and challenges the trust’s leadership. Stories of poor care are reported in local newspapers and the group’s campaign gathers pace, as more families speak out.
- February 2008 – Mid Staffordshire NHS Trust is awarded foundation trust status by Monitor
Meanwhile, the Healthcare Commission notes concerns over high mortality and begins to receive complaints from families and the Cure the NHS group.
- February 27, 2008 – Healthcare Commission announces a full investigation into Mid Staffordshire Foundation Trust mortality rates, governance and care of older patients
- May 23, 2008 – Royal College of Nursing general secretary Peter Carter visits the hospital and praises the trust in letter to local newspapers
On the same day the Healthcare Commission writes to trust chief executive Martin Yeates expressing major concerns about the safety of the A&E department.
- March 2009 – Mid Staffordshire Foundation Trust chair Toni Brisby resigns. Chief executive Martin Yeates stands aside on full pay ahead of the Healthcare Commission final report
Mr Yeates is suspended on full pay pending an investigation into his conduct. He resigns in May 2009 with £80,000 notice pay and a lump sum pension payment thought to be worth £360,000.
- March 2009 – Healthcare Commission publishes its report on Mid Staffordshire Foundation Trust
It reveals one of the worst scandals of poor care in the history of the NHS and detailed a chronic shortage of nursing staff, equipment problems, poor medical cover at weekends, a culture of bullying and drive for targets over quality and a lack of governance.
A draft copy of the report is leaked to a national newspaper. It includes a figure for the expected number of deaths due to poor care of 400 to 1,200 between 2005 and 2008.
The report focusses national attention on the trust and the families of victims begin a campaign for a full public inquiry. The government announces a series of further reviews of the trust and a case note review for affected families.
- April 2009 – Respected clinician Professor Sir George Alberti publishes his review of the procedures for emergency admissions and treatment at Mid Staffordshire Foundation Trust
His report highlights improvements, but also makes clear staff shortages and a need for long-term changes.
- April 2009 – Primary care tsar Dr David Colin Thomé publishes a review of lessons learnt for commissioners and performance managers following the scandal at Mid Staffs
He concludes that local warning signs were missed by the primary care trust, strategic health authority and other agencies.
He concluded: “A central theme of the failures at Mid Staffordshire hospital trust appears to be an over reliance on process measures, targets and striving for foundation trust status at the expense of an overarching focus on providing quality services for patients.
- July 2009 – Following further reports on Mid Staffordshire Foundation Trust and continuing calls for a full public inquiry, health secretary Andy Burnham announces an independent inquiry to investigate the failings at the trust
Robert Francis QC is appointed as inquiry chair.
- August 2009 – Antony Sumara appointed chief executive at Mid Staffordshire Trust for a two year period
The Cure the NHS group continues to campaign for a full public inquiry as poor care stories continue to emerge.
- October 2009 – Royal College of Surgeons review into Stafford Hospitals surgery department labels it “dysfunctional” and at times “frankly dangerous” for patients
The report is kept secret until the subsequent public inquiry in 2010. It also discovers problems in surgery dating back to 2007 when an earlier review recommended psychologists work with surgical staff.
- November 2009 – Robert Francis QC begins hearing evidence in private as part of his independent inquiry
- February 2010 – Robert Francis QC publishes his independent inquiry report into the poor care at Mid Staffordshire Foundation Trust
The report concluded patients were “routinely neglected by a trust preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care”.
The report was based on evidence from over 900 patients and families. Examples of poor care included calls for help using the bathroom being ignored; patients left lying in soiled sheets or on commodes for hours and left ashamed and afraid.
Other patients were left unwashed for as long as a month; food and drink was left out of the reach of patients and many were forced to rely on family members for help with feeding.
Mr Francis criticised hospital staff who did not ensure patients received adequate pain relief with the standards of hygiene described by Mr Francis as “awful”.
He called for a further investigation into why supervisory and regulatory bodies failed to spot the poor care at the trust, sparking renewed demands for a full public inquiry.
- May 2010 – General election campaign. The Conservatives promise a full public inquiry into the scandal at Mid Staffordshire, but the Labour says it would be damaging to the trust
- June 2010 – New health secretary Andrew Lansley asks Robert Francis QC to conduct a full public inquiry, with the power to compel witnesses to give evidence on oath
The public inquiry is aimed at investigating why poor care at Stafford Hospital between 2005 and 2009 was not spotted sooner by the commissioning, supervisory and regulatory organisations overseeing the trust.
- November 2010 – The public inquiry begins to hear evidence, as reported by Nursing Times
Nursing Times reporters Sarah Calkin and Simon Lewis reported from the public enquiry for Nursing Times, read their news reports into the Mid Staffordshire public enquiry.
- December 2011 – The public inquiry finishes hearing evidence after more than 12 months
Nurses and doctors detailed a bullying culture, which prevented many from speaking out, while the inquiry heard the wider system of NHS management was too interested in finances and meeting targets than delivering quality care.
In total 181 witnesses gave verbal evidence over 139 days, with more than a million pages of evidence examined. Witnesses included some of the most powerful figures in the NHS.
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