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Exclusive: Robert Francis criticises nurse leadership over failure to respond to Mid Staffs report

The nursing profession and its leaders have failed to adequately respond to the problems highlighted by the care failings at Mid Staffordshire, according to Robert Francis QC.

The views expressed by the chair of the Mid Staffordshire Foundation Trust Public Inquiry are likely to make uncomfortable reading for those charged with leading the profession.

Mr Francis has spoken exclusively to Nursing Times and our sister magazine Health Service Journal in his first in-depth interview since the publication of his landmark report in February.

He said his “impression” was that his report had been “well received by all the [healthcare] professions in general terms”.

Individually he had held “lots of conversations” with nurses, he said. These indicated “many nurses get the point” made in his report about the need for the profession to speak up for itself more.

But he criticised what he perceived as a lack of collective response from the profession as a whole and its representatives.

He compared the response to his recommendations from NHS managers and doctors’ leaders, saying: “They are taking this very seriously. The [medical] royal colleges are taking action.

“Putting it bluntly I have seen rather less of that from the nursing profession,” he said.

Mr Francis claimed he had seen “no reaction” to his call to strengthen the voice of nursing in order to speak up for frontline staff and prevent catastrophic care failings.

“I’m still not sure in terms of the professional voice I have heard much that gives me cause for optimism,” he told Nursing Times, noting that he understood concerns about needing to protect nursing staffing levels.

“There is a need to strengthen the voice of nursing so that what nurses need in their workplace to do their job effectively for patients is articulated better and stronger,” he said.

Mr Francis also cautioned nurses against complaining they were being unfairly focused on by ministers and the media, following the publication of his report.

“Any individual or group who says it’s not fair we are being criticised and someone else isn’t are missing the point,” he said. “The first and foremost duty any professional has is to fulfil their own responsibility and if that’s been shown not to happen their responsibility is to put that right.

“It isn’t a justification for inaction now for a nurse to say I’ve been criticised and doctors haven’t.”

In addition, he said there had been an “apparent misunderstanding” over his recommendations on staffing levels, and suggested unions had “got the wrong end of the stick”.

“I did not recommend there should be a national minimum staffing standard for nursing. The government was criticised for not implementing one, which it is said I recommended, which I didn’t.”

Instead, he said had recommended that the National Institute for Health and Care Excellence draw up staffing guidance “for each speciality on a service by service basis”, which he described as the “way forward to be more flexible”.

However, Mr Francis was equally critical of the government’s reluctance to bring in mandatory regulation for healthcare assistants, which he said was endangering patient safety.

“Without any registration system or its equivalent, I believe the public will be at risk. I am impressed by the fact that virtually every professional group including HCAs themselves consider this ought to happen,” he said.

“There seems to be everything in favour of it and if – as one survey suggested – they would be willing to pay for it themselves, I’m not sure what the problem is,” he added.

He did welcome the government’s commitment to national training standards for HCAs, but cautioned that it did not go far enough on its own. “We train doctors and nurses and we still like to keep tabs on them afterwards. I think the same should apply with healthcare assistants,” he said.

Mr Francis said the “jury is out” on the government’s plans to make student nurses work for up to a year as an HCA before starting their degree course.

His report has recommended a similar idea, but with potential students working in care settings for around three months. He defended the proposal saying a minimum period of hands on care was “essential” to “test a nurse’s aptitude”.

Mr Francis also used the interview to restate his view that NHS staff guilty of the most serious types of poor care – those resulting in serious injury or death – should face the threat of criminal prosecution.

Describing a scenario where such a prosecution might take place, he said: “I’m talking about the sorts of behaviour we saw so many distressing examples of in Stafford. Of absolutely appalling care, insulting to human dignity and in some cases life-threatening behavior – leaving people naked, unfed, covered in faeces.

“I refuse to believe that in some of these cases it was not possible for staff to do something about the dreadful things that were happening.”

He said the existing system of rules and regulations had failed to prevent the scandal at Stafford and new criminal offences were needed to properly “reflect the rightful anger and horror the public have about such things”.

Prosecutions would only happen, he said, if it was shown individuals could have been reasonably expected to have prevented it and did not. “We are not talking about the poor nurse who is so rushed off her feet, because she has inadequate support, she can’t look after all her patients,” he said.

Without the introduction of such laws, Mr Francis warned that public confidence in the NHS “will evaporate”.

“There is huge resilience among the public in terms of its trust of the NHS, but too many Mid Staffordshires and I am afraid you will find that going,” he warned.

The government has said it will await the outcome of a major review of NHS patient safety before making a final decision on criminal sanctions. The review, led by US patient safety expert Professor Don Berwick, started last month and is due to report its findings in July.


On Tuesday 14th May we will be hosting a Twitter discussion on Robert Francis’s comments. Join us at 1pm. Just follow #NTtwitchat and include this hashtag in your tweets to join the debate.


In a response from the government, health minister Dr Dan Poulter said: “We’ve been absolutely clear that the Francis Inquiry needs to be a catalyst for change in the NHS - and have swiftly brought in measures to improve the quality of care patients receive and ensure they will be treated with more compassion and respect.

“But in other areas, such as criminal sanctions or a duty of candour on individuals, we need to be careful that we do not unintentionally create a culture in hospitals that is less open, rather than more. We are considering these issues carefully.

“Regulation in itself is no substitute for a culture of compassion and effective supervision. Instead we are focused on recruiting the right people with the right skills for the job, and creating a culture that supports them to give safe care.”


The Royal College of Nursing said it would issue a “detailed and comprehensive” response to the Mid Staffordshire Foundation Trust Public Inquiry report in June, which would be based on the views of its members.

In a statement, it said: “We  take the findings extremely seriously, not only in terms of how they will impact on the nursing profession as a whole, but also as an organisation that seeks to represent the interests of nursing staff and their patients.”

· See next week’s issue for further response to Mr Francis’ comments from nursing leaders and other key stakeholders.

Readers' comments (45)

  • a professional body, who exactly has the responsibility for speaking as a body? The RCN?
    Is the RCN just a union speaking for some nurses and their own view of nursing?
    The NMC?
    Do they give a stuff about Nurses wellbeing and views, or are they there to 'protect the public' by squeezing our hard earned pennies out of our paypackets (yes...i know..cyincal, but you get the point).

    Seriously, its a real question - who?

    (ps: you ALL have to post using a 'name' (real or not) so we can follow the posts this is gonna happen lol!)

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  • I say Francis has ducked the issue of nurse staffing levels and whether there should be a minimum (exceptions could be allowed subject to justifications). It is also unclear where the role of HCA is to go - apprenticeship or equivalent to teaching assistant or both or just 'nursing' on the cheaper (c.f. PCSO's)

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  • I think that to set minimum staffing levels misses the point about the complexity of the care needs of many patients as well as the range of care needs that they might have.
    A system, used by Stafford, showed how many nurses were necessary and what competencies they needed to look after the patients they had on each ward. When I undertook a report on a death of a patient some years ago, the system showed that the ward was always understaffed and each nurse had to do the work of 1.5 people and at time the work of 2.
    There needs to be evidence that there is a manpower system that is flexible and will respond to the care needs of the people admitted to the ward. To set rigid levels will always give a Trust like this a cop out if they have overloaded the wards. The nurses must learn to say no to admissions if they cannot provide the care. It may mean someone looses a bonus for an A+E target but that is not the problem of the nurse on the ward who must say if they cannot meet the care needs of the patients.
    The nurse managers have been weakened and can only try and "influence" as they have no control over the nursing budget.
    Squealing and moaning will not do it. Nurses must get more business like and get figures to support their arguments and present their case for safe staffing levels.
    Nurses continue to be sent to the NMC because they have failed to find their voice and the patients are suffering as a result.
    The law doe not look at how busy the nurse is, only whether the patient had the care they needed.

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  • All Chief Nurses should have resigned and offered Nurses a new Leadership.

    Nurses are exploited and also need a Union that represents the views of the membership rather than the views of a self selected clique of promoted nurses in senior roles.

    Cynical but accurate. Our collective contribution to NHS is undervalued because we have invisible weak leadership.

    The delayed Chief Nurses Report shows such weaknesses in leadership.

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  • My father died unexpectedly last week having been on a hospital ward for 2 days. He had lung problems ( I don't want to go in to too much detail as his death is being investigated by the coroner)

    I am convinced he died because of inadequate staff training, a failure to enforce good practice guidelines, T&T scoring etc and low staffing levels.

    I am sure our family will not be the only one that has suffered an unnnecessary loss whilst in the care of the NHS recently. Nor do I have confidence that lessons will be learned from his death.

    I despair about what is happening in nursing today. I have always tried to nurse patients as if they were my own mother or father, I feel greatly let down.

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  • The trouble with recommendations is that this is all are, they are not enforceable.

    Why won't anyone take responsibility for short staffing, inadequate skill mix, lack of training, lack of support.

    What exactly does it take for anything to get better in the health system?

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  • Anonymous | 14-May-2013 11:11 am Yes leadership is weak but so too is the voice of most nurses.

    EVERY nurse must find their own personal leadership and take responsibility for their own actions. Not easy in the current climate but not impossible either.

    I have no idea how effective the new NHS Leadership Academy programmes will be in improving leadership but whatever it's impact there is nothing to prevent nurses starting to change the culture themselves. Small steps within nursing teams can have a profound impact. Nurses have to stop waiting for others to lead the change.

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  • leadership right from the bottom up is also vitally important. everybody involved in healthcare no matter how small their role have a part to play for which they are entirely responsible to themselves, to their colleagues, to their patients, to the organisation, to their representatives and to their community. every citizen is there to service society and not only to be served by it and by others.

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  • Can the system being worked within ever work?
    Its too large, centralised planning never works & accountability is low.
    If patients have more power and spending ability, they will improve the system.
    People know the poor hospitals, they know the competent nurses & avoid the non listening GP's. They will use the good services and help improve the poor ones.
    In 2013 we need fundamental change & simplification

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  • Professional nurse leadership in this country with a very few exception does not exist.

    At a National (Dept of Health) level we have a "nurse leader" who believes all problems can be solved by implementing rather silly philosophy based on the third letter of the alphabet!

    Does she turn her mind to really important issues like skill mix and nurse/patient ratios? The answer as you will all know is that she does not ! That sort of stuff she believes is something to be addressed "locally"

    At a local level "directors of nursing" are mere sycophants to Trust CEO,s "Savings" are these peoples reason for existence. A few less RGN's replaced (or not) by care assistants can always make the spread sheet balance! Speaking generally "directors of nursing" are a wast of space they have no regard for patients and even less for the nurses they are supposed to leading.

    Mr Francis is of course correct - nursing is a leaderless profession. Individual nurses do not support the RCN but are good at complaining when nothing ever appears to change for the better.

    The RCN of course needs to change but do do so needs the active support of the membership.

    Front line nurses suffering the effects of poor staffing should be not only reporting their concerns to local management but drawing the attention of the CQC to the issue which is one of patient safety.

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  • "The delayed Chief Nurses Report shows such weaknesses in leadership".Anonymous | 14-May-2013 11:11 am.
    Jane Cummings is waiting for Jeremy Hunt to tell her what to say!

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  • tinkerbell

    the enquiry appears to have been a face saving, arse covering managerial exercise, sorry to say Mr Francis QC you were led up the garden path too.

    To say you too have got the wrong end of the stick is a bit rich coming from muppets who don't know their arse from their elbow about nursing care except when it comes to making a fast buck out of other ordinary folks misery. Corruption rules OK.

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  • I agree with many of the comments
    The rcn have sold us down the river and there strategy and policy is made up by the chosen few and not by listening to their members
    They are corrupt and keen to take our money but what have they achieved in recent years
    They have failed many staff locally
    They failed nurses like Helena Donnelly at mid staffs
    Call time on the union and bring in new blood I can see no future for nursing until we have nursing leader who has the guts, vision and fight to tackle the government as well as poor local leadership within acute trusts and community services

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  • Susan Markham

    So nothing changes...

    Blame the nurses.

    Did we actually expect that anything would change?

    Call me silly - but I didn't.

    How many other ways can you say "whitewash" or "cover-up"?

    I am so glad I am hurtling towards retirement... looking forwards to a real job as a "greeter" at WalMart! :-)

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  • Susan Markham

    So nothing changes...

    Blame the nurses.

    Did we actually expect that anything would change?

    Call me silly - but I didn't.

    How many other ways can you say "whitewash" or "cover-up"?

    I am so glad I am hurtling towards retirement... looking forwards to a real job as a "greeter" at WalMart! :-)

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  • Anon 14/05 11:43 sorry about your dad, hope the truth comes out.Take care of yourself.

    Each and every one of us stand up get up speak up don't wait on some one else to do it especially don't wait on nurses in high places.
    I do my part by saying loud and clear that I cannot accept a new admission when there is no one available to look after the new patient. I call the site manager for help.

    Nurses are still too damm timid to speak up stand up get up to what is Right and Safe.

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  • Re anon 14/5 11:43
    My heart goes out to you. My mum died a couple of years ago on an over busy ward, with few staff and junior doctors. It still upsets me greatly.
    The staff didn't do anything wrong, the hospital did'nt do anything right, the nurses were inexperienced and just couldn't stretch themselves any more (2 trained, 3 hca's, 40 bedded medical ward, usually agency nurses), the hospital trust was to blame due to lack of staff. The ward (and similar wards) are still understaffed.
    You would have to break my legs to keep me in hospital. I don't think ours is any different to any other general hospital.
    This government and their poodle Cummings have a lot to answer for.

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  • I am sure not one self respecting nurse would condone any of the actions/incidents that took place at this hospital. If this is still happening anywhere else, on even a small scale, it has got to stop & stop now.

    However willful, deliberate, criminal actions need to be extrapolated from the incidents that happen because of lack of staff, supervision, resources or training.

    It is not easy to stand up & object particularly when management are not supportive or believing. Even strong people will find it hard & not everyone is that strong. Many will have felt alone in bringing to the attentions of seniors situations that are unacceptable.Most people are just scared for themselves & would rather keep their heads down.
    I know I would stand up & shout if I believed what I was doing was right but I also know from first hand experiences that it is very hard to fight against what is often intimidating behaviour.
    Nurses need strong leaders & this will take a cultural change in lots of organisations.

    As for staffing ratios,personally I don't agree with one size fits all. The thought of one nurse to 8 on a children ward (not all wards are for adults) is horrendous.

    ITU's have had ratios for some time now so what is so difficult about finding a formula that fits each area that dictates how many patients per nurse that area can safely deal with but still deliver a quality service?
    Could it be back to money & I believe, that many senior staff (managers & HCP) think nurses just moan about how much they have to do, do not realise the just how much dependencies of patients have increases over the last 20yrs because they don't actually do what nurses do now. We are not listened to anymore, and on the whole, we do not have the authority or respect we once had. Maybe we have lost sight of how to make our case & we need to take stock & be less emotional & more objective in our pleas. There may be areas who disagree with this & I am please for them that that is not the case but it is still the case in other areas.

    Finally, just a thought.
    Did anyone think the argument in the press this week about how many children child minders can & cannot look after was a bit ironic in the light of nursing staffing levels?
    They were falling out about whether it should be 3 or 4 per person & child carers saying how can anyone look after 4 toddlers at once?
    On the average children's ward nowadays where to be an in patient, the child will be very sick, the nurse who is often very junior can have 4, 5 and sometime 6 to look after.
    Whilst I am not saying child minding is easy, at least the child minder is not trying to get 5 lots of drugs out all at the same time or an incident form will need to be competed, monitoring a child on CPAP, IVT's, dealing with distressed, angry parents, trying to get a blood test request done when the computers are down etc, etc,etc.
    I bet referrering a fight between 2, 3yrs old whilst picking up a child who has fallen over & the other needing a nappy change would seem like an easy shift to the children's nurse????

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  • Whatever happened at Mid Staffs, and elsewhere, I find it totally inappropriate to label it and accuse anybody in the NHS associated with patient care of murder as seen in the national press and comments from the public

    the Oxford Dictionary definition of murder (COED 11th ed)

    "the unlawful premeditated killing of one person by another"

    I am not a legal expert but would describe many of the cases as death by professional neglect (for whatever cause but which also includes staffing shortage and working in situations which made it impossible to attend adequately to each patient, and most which have been well documented elsewhere.)

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  • Let's stop absolving ourselves of all blame here. It isn't just nurse leaders and managers at fault, although they are major contributors. What about your colleagues? Look around you. Why are your colleagues not standing with you and challenging management with you? Are you supoorting your colleagues when they complain? Obviously many are not. We are all responsible for our own actions. Those who keep their heads down are just as much to blame as anyone. It really isn't acceptable to keep blaming everyone else.

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