Patients 'routinely neglected' at hospital of horrors

Mid Staffordshire NHS Foundation Trust lost sight of its responsibility to provide safe care, according to the independent study launched after inspectors found between 400 and 1,200 more people had died there than would have been expected from 2005 to 2008.

Its report makes 18 recommendations for the trust and the Government including the introduction of measures to regulate hospital board executives.

Elite foundation hospitals will also be urged to make board information routinely available to the public.

But Julie Bailey, who founded the campaign group Cure The NHS after the death of her mother Bella at Stafford Hospital, described the report as "absolutely outrageous" and called for a public inquiry.

The Tories and Liberal Democrats are also demanding a full public inquiry but Health Secretary Andy Burnham said a second investigation he is setting up would meet those demands. That investigation will look at how trusts are regulated and monitored and the systems for identifying failing hospitals.

The General Medical Council said it is investigating several doctors from Mid Staffs to see if they should face disciplinary action while the Nursing and Midwifery Council is investigating at least one nurse and considering whether others should face inquiries.

The independent inquiry headed by Robert Francis QC highlighted serious management failings and contained dozens of examples where nurses neglected patients.

It revealed patients were left in dirty bedding and were

caused "considerable suffering, distress and embarrassment".

Some people suffered falls leading to serious injury, while nursing records and medical histories were incomplete.

Senior managers were described as being too focused on meeting targets, in particular the four-hour waiting time target for A&E.

"A&E was chronically understaffed in terms of consultants and nurses during the period under review," the report said.

Mr Francis said that many of the individual accounts indicated a standard of care which was totally unacceptable.

"Together, they demonstrate a systematic failure of the provision of good care," he said.

The inquiry concluded the trust's board – which exacerbated its problems by cutting staff to save 10m in 2006-7 – was "disconnected" from what was actually happening.

Mr Francis said he believed some staff had attempted to minimise the significance of a report by the Healthcare Commission which exposed failings, rather than reflecting on their roles in the trust's deep-rooted problems.

"I heard so many stories of shocking care," he added. "These patients were not simply numbers, they were husbands, wives, sons, daughters, fathers, mothers, grandparents.

"They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives."

He recommended Mr Burnham review whether to remove Mid-Staffordshire's status as a foundation trust – a supposed marker of excellence in the NHS.

Mr Burnham said he had asked the regulator Monitor to review its status and ordered another inquiry into how the failings were not detected earlier.

"This was ultimately a local failure, but it is vital that we learn the lessons nationally to ensure that it won't happen again – we expect everyone in the NHS to read the report and act on it," he said.

Patients Association president Claire Rayner said the voice of patients was "still being ignored up and down the country".

Main findings of inquiry

n Managers were too focused on targets rather than patient care.

n Patients were left unwashed, at times for up to a month.

n Requests for assistance to use a bedpan or get to or from the toilet were ignored.

n Patients were left in soiled sheets for "considerable periods of time".

n Razors were used on more than one patient, washing bowls were shared and patients did not have their teeth cleaned.

n Some patients were admitted to dirty rooms infected with the bug Clostridium difficile.

n There were chronic shortages of staff, particularly nurses.