A doctor in Stafford Hospital’s A&E was giving clot-busting drugs to a heart attack patient when the request came: go and work on the “minors” side. The doctor refused, but worried, investigators were told, that a more junior doctor might have felt bound to comply.
The reason was a clock. Since 2004, the national standard had been that 98 percent of A&E patients be admitted, discharged or transferred within four hours, and trusts were judged on it. At Stafford, staff told the Healthcare Commission, managers held them responsible for any failures. Nurses spoke of leaving meetings in tears and being told their jobs were at stake. One described an average shift as “pressure, pressure, pressure.”
The Commission broke down how long patients spent in the department, in ten-minute slices, from April to December 2007. One slice stood out: the last ten minutes before four hours were up, when there was a marked rush to admit, discharge or move patients. Doctors said patients with dislocated ankles were sent to wards before an X-ray because their time was nearly gone.
The hospital belonged to Mid Staffordshire NHS Trust, and in 2006/07 its board had a plan: stable finances and foundation trust status, which brought more independence. It set out to save £10 million, about 8 percent of turnover. More than 150 posts went, and the number of nurses fell sharply in a hospital already short of staff. The public inquiry later concluded that the board was slow to fix the nursing shortage because it wanted the books in order for its application.
Patients and families described what that looked like: people left in excrement in soiled bed clothes for long periods, water left out of reach. In A&E, the first check on new arrivals was left to receptionists with no clinical training. On some bays nurses had not been trained to read the heart monitors, and at times the monitors were turned off.
The hospital was not short of watchers. The strategic health authority and the Department of Health had scrutinised the trust. It appeared largely compliant with the Healthcare Commission’s standards. On February 1, 2008, the regulator Monitor authorised it as a foundation trust.
The warning signs were there. In January 2007 a Royal College of Surgeons report called the surgical department “dysfunctional.” That year a staff nurse made a serious allegation about A&E leadership, which management did not resolve. In April 2007 a published hospital guide showed more deaths at the trust than expected; the trust largely put that down to poor data recording. The Commission’s regional team knew of the foundation trust bid but hadn’t told its head office, and Monitor learned of the Commission’s concerns only after it had approved the trust.
When the Commission opened a formal investigation in March 2008, the other oversight bodies largely waited for its outcome instead of asking what they should do themselves. The truth surfaced partly through the mortality figures, the public inquiry said, but mainly through the persistent complaints of patients and relatives. One group, Cure the NHS, was led by Julie Bailey, whose mother had died at the hospital.
In February 2013 Robert Francis QC delivered the public inquiry’s final report. Among the causes he listed was an assumption that monitoring or intervention was someone else’s responsibility. He wrote: “None of them, from local groups to the national regulators, from local councillors to the Secretary of State, appreciated the scale of the deficiencies at Stafford and, therefore, over a period of years did anything effective to stop them.”