Skip to main content

Patients First and Foremost

The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry

This document sets out an initial overarching response, on behalf of the health and care system as a whole, to the Mid Staffordshire NHS Foundation Trust Public Inquiry (the Inquiry). It details key actions to ensure that patients are ‘the first and foremost consideration of the system and everyone who works in it’ and to restore the NHS to its core humanitarian values. It sets out a collective commitment and a plan of action to eradicate harm and aspire to excellence.

This is a watershed moment for the NHS and a call to action for every clinician, everyone working in health and care, and every organisation. Many thousands of committed, caring and hard working staff deliver good or excellent NHS care every day of the year. Yet in one hospital from 2005 to 2009 many patients received appalling care, and the wider system failed to identify the problem and then failed to share information and act on warning signs. This was unforgivable and must never happen again. Yet whilst the case at Mid Staffordshire NHS Foundation Trust was unique in its severity and duration, pockets of poor care do exist elsewhere and some of the features that contributed to the tragedy – patients and families ignored, staff disengaged or unable to speak up – point to wider problems.

Robert Francis’ first independent inquiry looked at what went wrong inside the Trust and reported in 2010. Since then, we have taken action to strengthen the focus on the quality of care and the safeguards to protect patients from harm, including through the work of the National Quality Board, the Nursing and Care Quality Forum, the improved processes for Foundation Trust authorisation, and the introduction of dignity and nutrition inspections amongst many other measures.

 But it is clear we now need to go further. This response starts from a simple premise and a simple goal – that the NHS is there to serve patients and must therefore put the needs, the voice and the choices of patients ahead of all other considerations. This response to the shocking findings of the Inquiry sets out a five point plan to revolutionise the care that people receive from our NHS, putting an end to failure and issuing a call for excellence:

A. Preventing problems
B. Detecting problems quickly
C. Taking action promptly
D. Ensuring robust accountability
E. Ensuring staff are trained and motivated