The Francis Report
LMS Response
Leicester Medical School
From: Communications
Sent: 05 June 2013 09:38
Subject: Message from the Chief Executive
Dear colleagues,
There is a story running in the media today regarding a lady who was in our
care in January 2012. It is distressing. There is little that we could say in
response which would satisfactorily explain how we failed this patient so
badly. However, I will share what we did issue in a statement:
“It’s clear that our failure to give Mrs Spilner intravenous fluids was a
catastrophic error for which we have apologised; we know that saying sorry
won’t bring her back but we at least want her family to know that we will not
avoid our responsibility, we are truly sorry. As regards the equally important
issue of the compassion shown to Mrs Spilner; since this happened in 2012, we
have changed the nurse leadership on this ward, increased staffing levels and
introduced hourly ward rounds. Again, we realise these actions will not alter
anything for the family but we hope that it shows we take their experience
seriously.”
On 17 March 2009 the Healthcare Commission published its report into the
severe failings in emergency care provided by Mid Staffordshire NHS
Foundation Trust between 2005 and 2008.
In response to the report, Alan Johnson, the then Secretary of State
commissioned two reviews:
Professor Sir George Alberti (National Clinical Director for Emergency Care)
looked at the hospital’s procedures for emergency admissions and treatment
and its progress against the recommendations in the Healthcare Commission’s
report
Dr. David Colin-Thome (National Clinical Director for Primary Care) looked
into how the commissioning and performance management system failed to
expose what was happening in the hospital.
Both reports were published on 30th April 2009
On 21 July 2009 the Secretary of State for Health Andy Burnham announced
an Independent Inquiry into care provided by Mid Staffordshire Foundation
Trust, to ensure that patients or their families have an opportunity to raise
their concerns, to listen and learn from their experiences so that further
lessons not already identified by previous investigations are learned. Inquiry
chaired by Robert Francis QC and reported on 24th Feb 2010. This report
looked at individual cases.
A Public Inquiry was set up by the Secretary of State for Health, who
announced it to Parliament on 9 June 2010. The Secretary of State’s purpose
in setting up the Inquiry was to examine the commissioning, supervisory and
regulatory organisations in relation to their monitoring role at Mid
Staffordshire NHS Foundation Trust between January 2005 and March
2009. The Inquiry looked at why the serious problems at the Trust were not
identified and acted on sooner, to identify important lessons to be learnt for
the future of patient care. The Public Inquiry was also chaired by Robert
Francis QC.
The mammoth public inquiry was chaired by Robert
Francis QC, right, described by solicitors who hire him
as "formidable" and "forensically exceptional". A
barrister specialising in the NHS and medical negligence,
he is highly skilled at getting to the truth and quietly
scathing when he feels censure is due.
Stephen Dorell
MP for Charnwood
Chair of the Health Select Cttee
Valeria Vaz
MP for Walsall South
Compassion in Practice – “The 6Cs” Care, Compassion, Competence,
Communication, Courage and Commitment.
Compassion in Practice (the nursing, midwifery and care staff vision and
strategy for England) was launched in December 2012 at the Chief Nursing
Officer’s Conference. Compassion in Practice was developed with nurses,
midwives and care staff up and down the country. There was an eight week
engagement period prior to the launch of Compassion in Practice when spoke
to over 9,000 people including nurses, midwives, care staff, patients, people
we care for and stakeholders. We also used social media to engage people in
the 6Cs and had over three million twitter impressions.
As well as the clear focus on the 6Cs, Compassion in Practice sets out six
areas of action to concentrate our effort and create impact for our patients
and the people we support. These six areas of action will be delivered
together as one programme to achieve the values and behaviours of the 6Cs.
Over the last three months nurses, midwives and care staff, as well as
stakeholders at national and organisational level, have developed
implementation plans to support the delivery of the values and behaviours of
the 6Cs.
To find out more and to see the implementation plans visit:
www.commissioningboard. nhs.uk/nursingvision
Requirement
All commissioning, service provision regulatory and
ancillary organisations in healthcare should consider the
findings and recommendations of this report and decide
how to apply them to their own work.
Each such organisation should announce at the earliest
practicable time its decision on the extent to which it
accepts the recommendations and what it intends to do to
implement those accepted, and thereafter, on a regular
basis but not less than once a year, publish in a report
information regarding its progress in relation to its
planned actions.
A shared culture in which the patient is the priority in everything done.
A system which recognises and applies the values of transparency, honesty
and candour.
Staff put patients before themselves.
They will do everything in their power to protect patients from avoidable
harm.
They will be honest and open with patients regardless of the consequences
for themselves.
Where they are unable to provide the assistance a patient needs, they will
direct them where possible to those who can do so.
They will apply the NHS values in all their work.
Fundamental standards of behaviour
Reporting of incidents of concern relevant to patient
safety, compliance with fundamental standards or
some higher requirement of the employer needs to be
not only encouraged but insisted upon. Staff are
entitled to receive feedback in relation to any report
they make, including information about any action
taken or reasons for not acting.
Fundamental standards of minimum safety
and quality – in respect of which noncompliance should not be tolerated.
Patient Safety
• Your knowledge!
– Scientific knowledge
– Apprenticeship
– Knowing your limitations (however, there is often
not a senior person immediately available)
• Your caring!
– What do you understand by caring? Does it have any
limitations for students/doctors?
Selection?
– Does the medical school promote caring or erode it?
• Your resilience!
Discussion groups
1.
2.
3.
4.
5.
6.
7.
Student selection
Caring (emotional)
Interprofessional caring
Whistleblowing. ‘Carers’/student
Do you feel apprenticed?
Resilience
Caring (knowledge)
Change has to occur, but:
The Medical School wants to change but only if the
change will improve patient care. In other words
any changes must be patient focussed, not politically
driven!
Examples of outcomes from discussion groups
All 1st year students should spend ½ day a week on the
wards as a volunteer Health Care Assistant
All 2nd year students should spend ½ a day a week on the
ward as a volunteer Nurse Assistant
The Medical School should clarify the pathways through
which students should raise concerns about fellow students
The Medical School should clarify the pathways through
which students should raise concerns about patient care
Many students do not feel apprenticed and want more
apprenticeship in the course