Chairman of the public inquiry into serious failing at Mid Staffordshire NHS, Robert Francis QC, made a total of 290 sweeping recommendations for healthcare regulators, providers and government in his 1,782 page report.
The report attacks local health authorities, and sharply criticises the trust board, but does not blame any one individual or organisation.
In his concluding statement, Mr Francis said what is required is nothing short of a "real change in culture, a refocusing and re commitment of all who work in the NHS, on putting the patient first."
The 290 recommendations are divided into five main areas, some of which would require new laws:
- New 'fundamental standards' of compliance, with clear means of enforcement
- Greater openness, transparency and candour
- Improved support for compassionate, caring and committed nursing
- Accurate, useful and relevant information
- Better healthcare leadership
New 'fundamental standards' of compliance, with clear means of enforcement
- Hospitals should agree lists of 'fundamental standards' about patient safety, effectiveness and basic care
- To cause death or serious harm to a patient by non-compliance should be a criminal office
- Individuals should be supported to report non compliance, and should be protected when they do
- Standards should be created by the National Institute for Health and Clinical Excellence (Nice) policed by the Care Quality Commission (CQC);
Greater openness, transparency and candour
- A 'duty of candour' should be imposed, by law, and deliberate obstruction of this duty should be made a criminal offence
- Complaints should be treated seriously when they occur, and questions answered truthfully
- Any patient who has been harmed by a healthcare worker should be informed, as should their family, regardless of whether the information will lead to a complaint
- Every provider trust must be obliged to tell the truth, as a contractual duty
Improved support for compassionate, caring and committed nursing
- Student nurses should have direct care experience under the supervision of a registered nurse
- Healthcare supporter workers should undergo consistent training, and should be regulated by a registration scheme
- A code of conduct should be established for those working with elderly, and vulnerable patients
- Nurses should be given more representation at leadership levels within hospitals
Better healthcare leadership
- A common code of ethics and conduct, based on patient needs and public expectations, should be adopted by all senior managers in the NHS
- Boards must be accountable for the presentation of information, and standards
- It should be a criminal offence to make a wilful false statement on issues of compliance or fundamental standards.