Learning from Experience Database - Serious Case Reviews

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Mid Staffordshire NHS Foundation Trust

The independent Inquiry highlighted a whole systems failure with on the Trust with poor standards nursing care at the centre of this.  Issues identified included failure of clinical leadership and professionalism; poor communication with patients and relatives; poor monitoring and recording of food and fluid intake; failure to respond to symptoms and requests for help e.g. patients left to soil themselves in bed, increasing risks of infection and pressure sores and call bells not answered.  The root causes of these failings and lessons were identified as follows:

  • Poor clinical practice, medication, infection control;
  • Poor culture and failure by professionals to speak out.
  • Poor care to go unchallenged and those who did speak up found themselves side lined, bullied, threatened.
  • Skills deficit regarding the care of people with dementia
  • Skills deficit re care of people with a learning disability
  • Absence of Person Centred Care
  • Absence of Dignity in Care
  • Poor communication
  • Poor recording
  • Nurses not taking responsibility for care delivered
  • Poor leadership and lack of professionalism
  • Nurses not taking a proactive approach
  • Lack of CPD and clinical updating

In March 2013, the Department of Health published First and Foremost, in which its commitment to providing compassionate, high quality patient care that protects the rights and dignity of patients. First and Foremost outlines a five point plan to remedy the deep rooted and systemic failings uncovered by the Francis Inquiry which focuses on:

  • Preventing problems
  • Detecting problems quickly
  • Taking action promptly
  • Ensuring robust accountability
  • Ensuring staff are trained and motivated

2013 February Public Inquiry into Mid Staffordshire NHS Foundation Trust Executive summary