Commission welcomes release of Mid Staffordshire Trust inquiry report

7 Feb 2013

The Health Quality & Safety Commission welcomes the release today of the report into the Mid Staffordshire NHS Foundation Trust Public Inquiry.

The report looks into the serious failings at the Mid Staffordshire NHS Foundation Trust, between 2005 and 2008. It makes 290 recommendations, which have the following broad themes:

  • foster a common culture shared by all in the service of putting the patient first
  • develop a set of fundamental standards, easily understood and accepted by patients, the public and health care staff, the breach of which should not be tolerated
  • provide professionally endorsed and evidence-based means of compliance with these fundamental standards which can be understood and adopted by the staff who have to provide the service
  • ensure openness, transparency and candour throughout the system about matters of concern
  • ensure that the relentless focus of the health care regulator is on policing compliance with these standards
  • make all those who provide care for patients – individuals and organisations – properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service
  • provide for a proper degree of accountability for senior managers and leaders to place all with responsibility for protecting the interests of patients on a level playing field
  • enhance the recruitment, education, training and support of all the key contributors to the provision of health care, but in particular those in nursing and leadership positions, to integrate the essential shared values of the common culture into everything they do
  • develop and share ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system.

Health Quality & Safety Commission Chief Executive Dr Janice Wilson says the Commission will be taking a close look at the report.

“While many of the learnings in the report are very specific to the English National Health Service and to a period of time in the mid-2000s, there are themes that are universal to all health care and that we can learn from in New Zealand.”

Dr Wilson says these themes include the need for:

  • consumer involvement and engagement, so the patient is the centre of focus
  • a common culture, that puts patients first and encourages openness and transparency about matters of concern
  • strong clinical leadership, and clear lines of responsibility for quality of care
  • high quality analysis of data so risks and issues are recognised and addressed early
  • clear and constructive relationships between different parts of the system – organisations need to talk to each other and share information.

“These are all areas in which the Commission has an active interest. We will be going through the Mid Staffordshire report in detail and will prepare a document on learnings relevant to New Zealand, which will be available later next week.

“We know from our own serious and sentinel events and mortality review reporting that things do go wrong. However, it is reassuring that there is no evidence of harm occurring on a similar scale in the New Zealand health system.”

Dr Wilson encourages every health professional in New Zealand to read the report and consider it in light of their own practice and systems.

The importance of consumer involvement echoes the themes identified by Health and Disability Commissioner, Anthony Hill, who has been pointing to the importance of a consumer-centred culture as a focus in New Zealand.

Last updated 08/02/2013