The Robert Francis Inquiry says staff contributions confirm that there was a “pattern of sub-standard service delivery”, at Mid Staffs rather than isolated incidents.
But clinical staff at the hospital largely escape blame.
His report says that while some of poor care was due to unprofessional behaviour, “the overwhelmingly prevalent factors were a lack of staff, both in terms of absolute numbers and appropriate skills, and a lack of good leadership”.
Although staff did raise concerns with trust management, both individually and collectively, the poor response they received dissuaded more to report concerns.
But the report does accuse clinical staff of “accepting standards of care…that should not have been tolerated”.
Within the A&E department, the source of much criticism in previous reports on Mid Staffs, Mr Francis’ report says there was a lack of management, and both nurses and doctors felt there was inadequate leadership.
One consultant told the inquiry that nurses were “hung out” in the department, and “not supported”.
One A&E doctor said: “The nurses were so under-resourced they were working extra hours. They were desperately moving from place to place to try to give adequate care to patients. If you are in that environment for long enough, what happens is you become immune to the sound of pain.”
The report found that the lack of staff in A&E contributed to the situation highlighted in the HCC report where triage was provided by unqualified receptionists.
One advanced nurse practitioner, who had worked at the trust for a long time, told the inquiry that triage nurses were moved to other duties because a ‘see and treat’ policy had been introduced. But in fact that had not been put in place, so triage effectively stopped.
“Therefore the waiting room became full of patients who were not being assessed in any speedy manner at all and they waited regardless of their condition,” the nurse said.
Nurses told the inquiry of pressure to meet the A&E four-hour waiting target, with patients being moved out of the department to beat the breach without being fully assessed, and of subsequently being told to “lie” to make sure target breaches were not recorded.
More to follow.