Notes on a scandal – how the Staffordshire public rose up to seek for justice

In September 2007, Mrs Bella Bailey was admitted to Mid-Staffordshire NHS Hospital Trust. She was ill, but not dying. After the first few days her family were so shocked at her treatment and the neglect of other in-patients they started a 24 hour vigil by Mrs Bailey’s bedside. Despite this constant watch, after eight weeks Mrs Bailey had a fall in the hospital and was given a massive overdose of blood thinner by mistake. She died on November 8^th 2007. Julie Bailey, her daughter, was sure that what she had witnessed were not isolated incidents. Julie wrote to the local press, asking whether other families had had similar experiences.

Over 40 people contacted her straight away and out of their shared experiences they formed a campaign group called ‘Cure the NHS’. After their second meeting, Julie wrote a six page letter to the (then) Healthcare Commission (HCC) (since replaced by the Care Quality Commission, CQC) outlining her mother’s experience, detailing other occurrences of neglect and a list of 66 examples of poor care that she and the other families had experienced. The HCC launched their investigation in May 2008 having realised that the hospital had unusually high death rates. The first result of this investigation was to demand better staffing in A&E, but this didn’t happen until October 2008. The HCC published their full report in March 2009, just days after mid-Staffs Hospital Chief Executive had been suspended and Chairman had resigned. Alan Johnson, the then Health Secretary apologised and launched two separate investigations. At his visit to the hospital days later he claimed that Mid-Staffordshire Hospital experiences were an ‘isolated case’.

Later that same month the Patients Association joined Cure the NHS to launch an online petition calling for a public inquiry into what went wrong at the hospital, backed by local MPs David Kidney and Bill Cash and later supported by David Cameron.  The two investigations quickly reported back and showed that although things were improving, there were still issues around staffing and ability to use equipment. By then the HC had become the CQC and the latter announced they would visit the hospital every three months to check on progress.

Astonishingly, in May 2009, MPs voted against ordering a public inquiry into the failings at Mid-Staffs, with health minister Ben Bradshaw saying it would “take too long and distract staff who are working to make improvements”. The Cure the NHS group took their campaign literally to the new Health Secretary Andy Burnham’s front door in Greater Manchester and towards the end of July Andy announced an independent inquiry, not the full public inquiry that had been requested. The group were hugely disappointed with the prospect of hearings being held in private and no one being held to account. In October 2009 the Conservatives agreed to launch a Public Inquiry if they won the General Election in the following year, and despite it being six months after the first report, the CQC were still rating mid-Staffs hospital as weak. In a farcical turn, the Dr Foster Hospital Guide published in November 2009 named Stafford Hospital as the ninth best in England for patient safety, just days before gall-bladder surgery at the hospital was stopped after two unexpected patient deaths!

The independent inquiry reported in February 2010, saying that the Mid-Staffordshire NHS Trust had become driven by targets and cost-cutting, and that poor care caused “unimaginable distress and suffering”. But why the neglect had persisted, who was responsible, how to prevent a recurrence – these questions remained unanswered. Questions also began to be asked about grounds for criminal investigations.

After the general election and the formation of the coalition government, Prime Minister David Cameron announced in June 2010 that there would be a public inquiry, and Robert Francis QC who oversaw the independent inquiry was appointed to chair it. Held in the Stafford Council buildings public witnesses were first called in November. Accounts of heartbreaking neglect, ruthless coercion, bullying and appalling distress were heard; ‘good’ staff in tears at the pressure from understaffing; concerns raised and then dropped; action requested but not checked upon; reassurances sought on paper not in person; pressure to show financial viability with little concern for quality and safety; endless passing the buck between management at all levels.

Hospital is still where most people die, but from 2005 to 2009 it is estimated that between 400 to 1200 people died needlessly at Mid-Staffs. What exactly were the senior management and hospital Board doing during this time? Robert Francis QC spent 139 days listening to witnesses and has had to review about one million pages of evidence. Today he will issue his report, having sent advance warning letters over the past couple of months to those who are named as bearing some responsibility. What Julie Bailey and the Cure the NHS campaign are hoping to see today is that their pain has been heard and turned into solid proposals to rebuild a culture of safety and care in the NHS. It’s not just a task for the NHS, but for wider society from which staff are drawn – we need to have greater respect for the role of caring and the elderly, and be prepared to take responsibility.

However the government and NHS culture have added massive challenges ahead. We have a centralised NHS in which fear and figures reign. Such is the size of the NHS, the central control and grip have got ever tighter as the demands have increased and staff lose sight of who they are serving. Transparency alone will only deliver manipulation. Accountability to communities and flexibility to respond to local need is a necessary precursor to changing attitudes.  The government also need to lead on honesty on what is affordable in the NHS and what can be expected. Professionals need to see patients as equals – intimidation and arrogance is intolerable – and they should welcome volunteers onto wards and into supporting advocacy roles for patients. Practical, significant improvements can be made in how we regulate and performance manage hospitals and staff, and I hope Francis will recommend legal responsibility for hospital Board members. But ultimately clinicians and managers at all levels need to accept – must be made to accept – that when things go wrong, the right response is to humbly sit down with those involved, talk through the issue and apologise.

Nothing will bring back lost loved ones. But Cure the NHS gives us all hope, because ordinary people got involved, persisted until they were heard and campaigned for justice. Today we will hear whether they think they succeeded.