Transcript Mid Staffordshire Inquiry - Southern Health NHS Foundation

Mid Staffordshire Inquiry
How can we learn?
Staff Listening Exercise
Spring 2013
• 350 bed general
hospital in Stafford
area
• One of two hospitals
run by Mid
Staffordshire NHS
Foundation Trust
Trust
• Authorised as an FT
in 2008
Unexplained Deaths
“Care at Stafford was "appalling",
inadequately trained staff who were too few
in number, junior doctors left alone at night
and patients left without food, drink or
medication as their operations were
repeatedly cancelled. Receptionists with no
medical training were expected to assess
patients coming in to A&E, some of whom
needed urgent care “
1st Inquiry (2010) – Patients, family, staff
testimonials – 18 recommendations
2nd Inquiry (2013) – Role of regulators and
national bodies – 290 recommendations
They missed the
warning signs
Patient stories
Mortality
Complaints
Staff concerns
Whistleblowers
Governance issues
Finance
Staff reductions
Stories from patients
and their families
“ For many patients the most basic elements of care were neglected .. some
patients needing pain relief either got it late or not at all. Others were left
unwashed for up to a month. Food and drinks were left out of the reach of
patients and many were forced to rely on family members for help with
feeding. Too many patients were sent home before they were ready to go, and
ended up back in hospital soon afterwards.
The standards of hygiene were at times awful, with families forced to remove
used bandages and dressings from public areas and clean toilets themselves
for fear of catching infections.
Patients' calls for help to use the toilet were ignored, with the result that they
were left in soiled sheeting or sitting on commodes for hours often feeling
ashamed and afraid.
Misdiagnosis was common.”
Sir Robert Francis QC
The people behind
the stories …
Recommendations
• Common values and
fundamental standards for the
whole NHS
• Openness, transparency and
candour
• Compassionate, caring,
committed nursing
• Strong patient centred
healthcare leadership
• Accurate, useful and relevant
information
• Culture change not dependent
on Government
Values for the NHS
• Put patients first
• Staff put patients before themselves
• Staff do everything in their power to protect
patients from avoidable harm
• Openness and honesty with patients regardless of
consequences for themselves
• Direct patients to where assistance can be provided
• Apply values in all our work
Fundamental Standards
• Prescribed medication given
• Food and water to sustain life and stay well
being supplied and any help needed is
given
• Patients and equipment kept clean
• Assistance where required provided to go
to the toilet
• Consent for treatment obtained
• Care and Compassion
Openness and
candour
• Openness: enabling concerns and
complaints to be raised freely and
fearlessly, and questions to be
answered fully and truthfully
• Transparency: making accurate and
useful information about
performance and outcomes available
to staff, patients, public and
regulators
• Candour: informing patients where
they have or may have been
avoidably harmed by healthcare
service whether or not asked
Our Values
Our first response
Looked at all 290 recommendations:
–
–
–
–
What we think we already do well
What is already in our plan for 2013-14
Where we know we need to improve
What would be new for us
Briefing available at this session and on our
website which summarises our response
What do you think we need to do?
On our website:
How can we at Southern
Health learn from Stafford?
Gather in groups of 5-6 to discuss
what Mid Staff means to you,
your team and your patients and
to the Trust
A. If you were Chief Exec for
a day, what 3 things would
you do at Southern Health in
response to the report
B. What 3 things would you
do or change at Southern
Health that cost little or no
money?
C. What 3 things do you/your
team do really well that we
need to make sure we do
across the whole Trust
(leave your name/ contact details)
D. What would you change to
make it easier to raise
concerns?
What happens next?
We’re running sessions like this at all the
Briefings over the next few months
At the end we’ll collate all feedback and
decide how to act on your suggestions
We’ll share this with you in the Weekly Staff
Bulletin and on the Trust’s website
At the Briefings this time next year we’ll ask
you how we’re doing