A trust described as ”appalling” in one of the most critical NHS regulatory reports of recent years ”lost sight of its real priorities” in its desperation to become a foundation.

The Healthcare Commission uncovered failings including serious understaffing, lack of training and multiple management failures when it carried out an inquiry into standards of care at Mid Staffordshire foundation trust’s emergency services.

Mortality rates for the trust had been high since April 2003. Last year, these triggered the commission’s investigation.

The commission’s report said in its ”drive to become a foundation trust it appears to have lost sight of its real priorities”, causing it to further cut already low staffing levels to save money.

Monitor, which granted the trust foundation status a month before Healthcare Commission inspectors officially began their investigation, said it had been aware of high mortality rates but had been satisfied they were not a sign of poor care or governance.

Monitor executive chair Bill Moyes said the regulator had changed its processes following the Mid Staffordshire scandal and now asked the Healthcare Commission for any information it had about aspirant foundation trusts before it approved them.

Better links

Mr Moyes said: ”We assumed in the past people would come to us with information. What we do now is go to the Healthcare Commission locally and nationally and ask them quite specifically.”

He added Monitor was paying more attention to quality of care in its accreditation process: ”It has increased through the four years we have been doing assessment. It is now as important if not more important than the other things we do.”

He said: ”Everyone in the local health economy without exception thought the main problem was coding. My sense is the standard mortality ratio was the issue that attracted attention [from the commission] but the report is about poor aspects of care.”

Investigations for NHS West Midlands had attributed the figures to issues including coding and the availability of end of life care.

NHS West Midlands interim chief executive Peter Shanahan said the strategic  health authority’s response to high mortality rates at Mid Staffordshire, and several other trusts in the region, was to commission an investigation by Birmingham university in spring 2007.

The outcome was a research paper which concluded there was ”little or no evidence that a high standardised mortality ratio systematically reflects poor quality of care or a failing hospital”.

Focus on care

Mr Shanahan said the commission report demonstrated boards needed to pay attention to care, as no source other than mortality rates had suggested a problem.

”It is important people realise it is about poor standards of care rather than see it in terms of numbers,” he said.

”There is a significant difference between [hospital standardised mortality ratios] and individual patients’ experiences.

”The Healthcare Commission themselves rated Mid Staffordshire as ‘fair’ for 2006-07 and ‘good’ for 2007-08 [for quality of services].”

South Staffordshire primary care trust chief executive Stuart Poynor said the PCT had looked at mortality ratios from spring 2007 when the SHA-wide examination began.

He said he spoke to patients, a campaign group and GPs about the trust but no other information seen by the PCT had revealed problems. ”I personally visited GP practices and while there were concerns there was nothing brought to the PCT’s attention at the level [of the report].”

Improving practice

Mr Poynor said the PCT was now engaged with the trust’s clinical governance and working to ensure care continued to improve.

Healthcare Commission chief executive Anna Walker said: ”These were appalling standards of care, and we don’t often use that phraseology.”

She said: ”We had no idea Monitor’s board was looking at this trust, none. I discovered by accident after they had taken the decision. That is why it has been so important to have a [new] process in place.”

The report prompted health secretary Alan Johnson to apologise to patients and order an independent review of the trust’s accident and emergency services. He said: ”I would urge every manager and clinician to digest [the report’s] findings to ensure that these events are never repeated.”

Emergency failings

  • Receptionists performed accident and emergency triage
  • Just one consultant covering A&E for three months
  • Minor illness patients prioritised over serious ones to avoid four-hour waiting breaches
  • Emergency patients left in ”dumping grounds” after admission
  • Nurses not trained to use cardiac monitors
  • Patients left in wet or soiled sheets
  • Surgical patients overseen only by newly qualified doctors at night
  • Board meetings dominated by finance, targets and foundation status
  • Deaths deemed to be ”predictable” were not
  • Some trauma patients left in a ”no man’s land” between wards
  • Resuscitation trolleys unchecked and with out of date medication
  • Patients left ”nil by mouth” for several days after cancelled operations.