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Evidence of Mid Staffs care failures vanished

Vital evidence of concerns raised by nurses about staff shortages and care failings at Mid Staffordshire Foundation Trust has disappeared into a “black hole”.

More than 500 incident reports made by trust staff have been misplaced, the public inquiry into failings at Mid Staffordshire has heard.

The disappearance of the reports has led to a delay in scheduled appearances at the inquiry of senior nursing figures, including Royal College of Nursing chief executive and general secretary Peter Carter.

The inquiry heard nurses at the trust had completed “in the region of 500 or so incident or accident forms” that could not be found.

The trust presented the original Healthcare Commission investigation with 515 official concerns raised by staff, including nurses, about care on wards 10, 11 and 12 between April 2005 and August 2008. Of these, 37% related to staffing. Across the whole trust, 93 incidents relating to staff shortages were logged in just two months between July and August 2007.

According to the Healthcare Commission’s report, published in March 2009, none of the incident reports was “drawn to the attention of the [trust’s] board”.

Despite repeated requests by local campaign group Cure the NHS, the documents have still not been found.

The loss of the reports chimes with claims made to Nursing Times by union representatives and former nurses at the trust when the scandal broke two years ago.

Elizabeth Clare, who worked in the accident and emergency department, said she filled in countless incident report forms but without response.

RCN West Midlands regional director Patricia Marquis told Nursing Times that incident reporting forms submitted by staff appeared to “fall into a black hole”.

The inquiry heard the trust’s legal counsel believed all relevant evidence had been handed to the inquiry but searches on the inquiry’s computer system have failed to uncover the missing forms.

Mr Carter was due to appear last week, along with other RCN representatives. But Cure the NHS called for his appearance to be postponed while the missing reports were found, so they would have the opportunity to question him on the concerns raised.

Jeremy Hyam, counsel for the campaign group, said: “We just can’t believe that [RCN] members would be making these sort of complaints without… some sort of union backing or knowledge.

“We were seeking these documents [so we would be able] to put them to him [Peter Carter] in a meaningful way, having analysed or digested them.”

Inquiry chair Sir Robert Francis ordered Mr Carter’s verbal evidence be put back while the hunt for the missing documents continued.

The inquiry is the second investigation into the trust. It is focusing on why organisations regulating the trust failed to spot what was happening.

It is also examining the role of the professional bodies and unions, including the RCN, and why members’ concerns were not escalated.

In a statement submitted to the inquiry, Mr Carter admitted the union was not aware of the complaints at the time.

Reading from Mr Carter’s statement, Mr Hyam said: “It’s clear [the incident forms] weren’t being acted upon.”

Readers' comments (12)

  • Did someone mention criminal conspiracy?

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  • Whilst we have to be careful not to make unfounded accusations, l am certainly not surprised to hear that these documents have gone missing.

    Over the two decades, it seems to me that employers are now more concerned with protecting themselves from criticism (damage limitation) than they are getting to the root of the problem and finding a solution.

    Unfortunately, l believe that they have only followed the lead of their political masters!!

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  • Surely these nurses made copies of the incident reports they sent in.

    Not to do is negligent - and probably compromises their NMC code - doing everything that they possibly can to make the patient safe.

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  • If they were using a paper system then one would expect that there should be a carbon copy somewhere. However I am all too aware that the books themselves as well as paper copies can go missing. Hence why I oversaw the introduction to an electronic reporting system and once completed and submit is pressed, the record cannot be destroyed or hidden.

    I know through my work investigating and controlling the incident and risk systems that I have made many promises to the Nurses and others that I will flag up any concerns to managers. The managers may not always like the news I give them but I am here for the patients and staff and not to make management happy.

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  • Manuscripts don't burn...

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  • What a surprise!!

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  • How convenient!

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  • A whitewash from start to finsih. The corruption taking place within the UK and within the NHS is staggering. We must be one of the most bent countries in europe.

    As said above this is a criminal act of conspiracy to pervert an inquiry.....but nothing less than i'd expect from NHS mangers.

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  • These days no-one appears to want to be accountable for their actions or ommisions, yet they are happy to reap the rewards.

    When the loss of these documents is investigated, start at the source, and work up until someone says, "l don't know what happened to it" then discipline that person and or reduce their grade.

    This would seem to me to be just and equitable at whatever level, the complaint was lost.

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  • Why am I not suprised. I am seeing an image of a paper shredder in my mind right now...

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  • I work in a westcountry hospital and I have a feeling that these computerised incident forms often vanish into the ether. I would actually put money on some being 'deleted' or ignored.
    When we had the old fashioned incident books on the ward you always had a carbon copy to fall back on, you knew what people had been reporting and you at least had an idea of what was failing in your own area.
    You also knew when a whole form in triplicate had been ripped out which while rare, spiked some controversy.
    Now, I personally have written many, many incident forms on the computer system, especially regarding shortages of staff in relation to the workload and have never once had feedback from them, nor have staffing levels improved. I have only had feedback from two of the probably more than 70 incident forms I have ever written during my decade as a nurse, and one of those had to be acted upon because it relates to an NMC case against another nurses conduct - one the Trust was unable to ignore.
    I feel that the whole incident reporting system fails the staff that take the time to say when there is a problem, that not only affects the staff, but also in many cases, the actual patients, particularly when time on the wards is so precious.

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  • michael stone

    Things get invented as well - an organisation I shall not name here, mentioned non-existent conversations in its response to the PHSO ! Weirdly, it also seemed to have extensive notes about everything, however trivial, except it had 'no minutes' for the most crucial meeting in a chain of events !

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