System failure The scandal at Mid-Staffordshire Hospital remains just as shocking almost a year after it was first reported. A Socialist Health Association Conference last autumn debated what could be learned from it, and Richard Staines listened in

While it would be easy to find a single person to blame for the failings at Mid-Staffordshire NHS Foundation Trust, the verdict of the experts speaking at the conference was that it was a system-wide malaise that caused standards to drop so low. A jumbled mess of an external regulation system and an internal system that discouraged staff from speaking out about their concerns all contributed to the failings  and ultimately unnecessary deaths  at Mid-Staffordshire Hospital. There was also considerable anger that the government had not launched its own public fact-finding inquiry into the grim happenings at the hospitals emergency department.
To recap, the previous independent health regulator, the Healthcare Commission (HC), launched a special investigation into Mid-Staffordshire between March and October 2008 after it was alerted to high mortality rates at the hospitals emergency department. This was despite the fact that the hospital had declared that the quality of its services were good in the HCs Annual Health Check. Spot checks found a lack of protocols at the department, insufficient nursing staffing levels, with patients being assessed by receptionists without clinical training. There were too few doctors and the department was lacking in basic equipment, such as a defibrillator.
These were just some of a catalogue of failures that were found to have contributed to appalling lapses of care at the organisation. Mortality rates in the emergency department were between 27% and 45% higher than expected by the Commission  the equivalent of between 400 and 1,200 excess deaths. The findings were published in a scathing report in March 2009, provoking widespread public condemnation.
The question on everybodys lips was how the many organisations that are supposed to uphold standards in the NHS failed to identify and solve the problems at Mid-Staffordshire. Conference participants heard that in the end, it fell to local newspapers to raise concerns about the hospital prior to the intervention of the Commission.
Frances Blunden, senior policy manager at NHS Confederation, which represents most of Englands hospital trusts, said the poor standards went unnoticed for a long time because of excessive amounts of regulation. Blunden said the NHS Confederation identified 69 different bodies auditing against 698 standards. These meant that regulatory activities at hospitals across the country are often duplicated. It also meant they were repeatedly asked for the same information over and over again, by different auditing bodies, Blunden told delegates. She said: If you take any trust, they will tell you in no uncertain terms that they are facing huge numbers of information requests. There is a danger that they wont see the forest for the trees.
This tangled web of regulatory bodies could be having a perverse effect by giving false assurances for failing organisations, she warned. Blunden told the conference: It gives a false sense of reassurance, everybody thinks it is somebody else’s job, it might encourage some trusts to abdicate their responsibility. They may think it is the manager’s or the PCT’s job to do that … The amount of regulation is at a very high level  it needs to be more effective to pick up where we have conflict or problems.
Cathy James, deputy director of the organisation Public Concern at Work, an organisation aimed at helping whistle-blowers raise concerns about workplace issues, criticised Mid-Staffordshire trust for a culture of secrecy. She said that Mid-Staffordshire’s whistle-blowing policy discouraged staff with concerns to come forward to management. It was very long, it put duty of fidelity above everything else and it was very legalistic, she said.
Meanwhile, Peter Walsh, chief executive of the charity Action Against Medical Accidents, said some organisations could also be failing to detect poor care because of lax reporting systems. His organisation had sent a freedom of information (FOI) request to Maidstone and Tunbridge Wells NHS Trust, the site of the famous C diff scandal, asking how many referrals there were to regulators such as the General Medical Council and Nursing and Midwifery Council. The Trust could not give any information before April 2009, including the period between April 2004 and September 2006, when as many as 90 patients died because of an uncontrolled C diff outbreak. He added that a similar FOI request to Mid-Staffordshire Trust revealed numbers of referrals, but no details about what they were for. Consequently, he called for a registration scheme for NHS managers to improve standards. Nurses find themselves in front of the Nursing and Midwifery Council. There is no such responsibility on management, apart from a moral and ethical responsibility, he said. Walsh said that a lack of a full public inquiry into Mid-Staffordshire was hindering any further fact-finding missions.
In April 2009, the government commissioned its national clinical director for emergency access, Sir George Alberti, to review procedures in the emergency department. Meanwhile, the national clinical director for primary care, Dr David Colin-Thome produced a document investigating the lessons that commissioners and performance managers could learn from the controversy. Walsh said that neither of these documents went far enough. He said: Everything that we had in place failed to work. How did it slip through?
They [the government] have completely refused to have a full public inquiry. If you dont have a public inquiry into a system failure where 400 1,200 people have lost their lives, when would a public inquiry ever be justified? How many people died in the Paddington railway crash? We had a public inquiry into that.
Until there is a full public inquiry, where key figures at the hospital could be called to account, the speculation about the real causes and the real story behind Mid-Staffordshire will continue.

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