A “plethora” of agencies, commissioners, regulators and professional bodies failed for years to act on warning signs which should have alerted the NHS system to serious failings at Mid Staffordshire Foundation Trust, the Francis report has concluded.

Writing to health secretary Jeremy Hunt upon publication of his report, Robert Francis QC said the system’s failure to respond adequately to systemic problems at the trust had a number of causes, including:

  • a culture focused on doing the [NHS] system’s business, and not that of patients;
  • an institutional culture which ascribed more weight to positive information about the health service than to information that could imply cause for concern;
  • standards and methods of measuring compliance which did not focus on the effect of a service to patients;
  • failure on the part of many agencies to share their knowledge of concerns;
  • assumptions that monitoring, performance management, or intervention was someone else’s responsibility; and
  • a failure to appreciate “until recently the risk of disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation” in the NHS.

The report rejected what it described as a “constant refrain from those charged with managing, leading, overseeing or regulating the trust’s provision of services that no cause for concern was drawn to their attention”.

It listed a series of the “more significant issues that were in fact identified or identifiable throughout the period” leading up to the Healthcare Commission’s report on care failures in Mid Staffordshire.

These included the trust’s loss of its “star rating” – from three stars down to zero – in 2004; a series of critical peer reviews on aspects of the trust’s services in 2005 and 2006; “serious concerns” of the trust’s auditors about its risk management and the reliability of its compliance with standards; whistleblowing by a staff nurse in 2007; a savings plan and associated staff cuts which appeared to have attracted no “detailed scrutiny” from the strategic health authority for their potential impact on safety and quality; and the Healthcare Commission investigation itself.