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Learning from serious care failings

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On 6 February, Robert Francis QC published his Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Building on the work and conclusions of the first inquiry (accepted in full by the DH and Trust Board), it comprises a daunting three volumes, 1,700 pages and 290 recommendations.

The report's focus is on acute care in England; specifically, serious failings at the Mid Staffordshire NHS Foundation Trust which occurred between 2005 and 2008, leading to up to 1,200 unnecessary deaths.

Lessons for other sectors
While Francis acknowledges he will not directly address how the lessons from Stafford might be applied to different parts of the health economy, he states 'there are likely to be implications in the lessons and recommendations for other sectors, which must be borne in mind in implementing them, by those charged with doing so.'

The report's core message is relevant to all: 'put patients first'. It stresses the need for 'a relentless focus on ensuring patient safety and the provision of at least a minimum quality of care' and demands a culture change across the NHS, encompassing fundamental standards; transparency; openness; and accountability.

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