Francis Report: Investigating high mortality rates

Published on Saturday, 09 February 2013 16:39
Written by Sir Brian Jarman, OBE

The Francis report of the Inquiry into why the regulators did not detect the poor care at Mid Staffordshire NHS Trust was published on 6 February 2013

The Inquiry cost £13m, sat for 139 days, heard 164 witnesses in person (352 in total), and had 64,319 documents running over 1,190,648 pages. It has given probably the most detailed insight ever into the workings of the NHS.

About 25 organisations were involved in one way or another with the quality of care in the NHS, the main ones being the Healthcare Commission and Monitor (for Foundation Trusts). The constant theme was that they were unaware of the problems until the Healthcare Commission investigation that started in March 2008 and lasted a year. The HCC's March 2009 report of its investigation described an 'appalling' standard of care at Stafford Hospital.

In retrospect, it is clear that there were several warnings of possible problems at the hospital.

In January 2001, adjusted hospital death rates, known as Hospital Standardised Mortality Ratios (HSMRs), which had been calculated at Imperial College, London since 1999, were published in the first annual Dr Foster Hospital Guide. An HSMR of above 100 indicates that the hospital has deaths than expected by national norms for England.

The Mid Staffs 1998-99 HSMR figure for was significantly high (108[r1] ) and the three years HSMR for 2005-6 to 2007-8 was significantly high at 112. For 2006-7 it was 127, one of the highest in England. The 3-year observed deaths exceed the expected deaths by 500 deaths (range 400-600).

Another early indicator was the January 2002 clinical governance review by the Commission for Health Improvement (the predecessor to the HCC), which  noted "urgent action required."

The West Midlands Strategic Health Authority was the organisation responsible for performance management of the trust. In early 2007, when the Trust was starting its second application for Foundation Trust status, the SHA, having seen the HSMR of 127, employed Mohammed Mohammed and others at Birmingham University (known to be non-supporters of HSMRs) to evaluate the HSMRs methodology. The SHA's current Chief Executive told the inquiry that "A close reading of the evidence suggests that having spoken to the trusts affected in May of 2007 the SHA accepted their assurances and in commissioning the Mohammed report had already decided that there were no significant problems with quality of care underlying those statistics." During the inquiry oral hearings the word 'hindsight' was used 489 times and "benefit of hindsight" 378 times.

In April 2007 the Dr Foster Unit in the Imperial College Faculty of Medicine started sending monthly mortality alerts to the chief executives of trusts that had a death rate for particular diagnoses or procedures that was double the national value. The alerts had less than 1 in 1,000 false alarm rate. In July 2007 they sent the chief executive of Mid Staffs a mortality alert for operations on the jejunum (part of the bowel) and by November 2007 they had sent three more alerts -  for Aortic, peripheral and visceral artery aneurysms, Peritonitis and intestinal abscess, and Other circulatory disease. The HCC also sent three alerts of their own.

In March 2007 the Trust's medical director, asked the Royal College of Surgeons to review the hospital's colorectal and laparoscopic cholecystectomy service[r2]  and the College made several recommendations but didn't follow-up that they had been implemented. In a second review in 2009 they found concerns with the cases of four of the five surgeons and noted that the Trust was providing "grossly negligent" care.

In October 2007, a doctor in the Emergency Department  described it as "an absolute disaster," and said "...as a department, we were immune to the sound of pain."

In November 2007, Julie Bailey spent time in the hospital when her mother was ill. She was so dismayed by the poor care her mother received that she formed the campaign group "Cure the NHS" and it was this group that campaigned for the Public Inquiry.

The Inquiry heard evidence from the regulators about the politics of patient safety. The then chair of Monitor, said: "The culture of the NHS, particularly the hospital sector, I would say, is not to embarrass the minister." The Secretary of State for Health, Andy Burnham, said "The impression of us all was that we would just, you know, constantly do what was meant to be the thing that Number 10 wanted or that we were all, you know, unthinkingly piling this stuff through. We weren't."

The 1,700 page Francis report has made 290 recommendations, many of them similar to the 2001 report of the Bristol Royal Infirmary Inquiry. The Prime Minister, David Cameron, spent two hours in the House of Commons answering questions from Members about the report and asked the NHS medical director, Sir Bruce Keogh, to conduct an immediate investigation into care at the hospitals with the highest mortality rates.

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