PATIENTS were denied pain relief, stranded in soiled bed clothes and marooned without drinking water.
As Stafford Hospital’s bosses sacrificed basic care on the altar of financial responsibility and an obsessive compliance with a culture of box ticking, between 400 and 1,200 people on their wards died.
Amid widespread outrage, the Government asked Robert Francis QC to investigate how the scandal could have shamed one of the most respected institutions in the country.
This week, he has published his findings and made almost 300 recommendations in a bid to overhaul a system which, in Stafford, ‘ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety’.
But why has it come to this and what can be done to prevent Stafford from happening again at hospitals throughout the land, including those used most regularly by Mail readers in Burton and Derby?
In a bid to find answers, the Mail spoke to William Saunders, a former chief executive of East Staffordshire Borough Council, who has just retired as a non-executive director of Burton Hospitals NHS Foundation Trust after nine years’ continuous service.
He was interviewed on the understanding his comments related to the NHS as a whole rather than Queen’s, which remains ‘in significant breach’ of regulator Monitor’s guidelines at a time when the hospital is struggling to save millions of pounds while improving and expanding its services.
Mr Saunders, it was clear, had reached some devastating conclusions about the ‘NHS system’, as Francis called it, with Monitor just one element in the firing line.
“Why is it assumed that regulation achieves a great deal?” he said.
“It’s down to managers and people who are running trusts to make sure things are running properly, not regulators.
“Monitor is more worried about making sure nothing goes wrong and not getting blamed for it than making sure things go right.”
So far, so caustic – but Mr Saunders had only just started.
“It’s not just the bullying and fear culture that operates from the Department of Health downwards, but from some of the regulators like Monitor,” he said.
“It’s because of this bullying and fear culture that executives are afraid to stand up for what they believe is right for their trust because they might get black-marked in the health service as being awkward and difficult by various regulators.
“Therefore, it’s worth asking ‘who really runs your hospital’?
“Is it the trust board; is it the regulator; or is it the Department of Health?
“It should be the trust board but, in reality, is it?
“In my experience, the last people running the hospital is your trust board.
“I would say it’s the regulator and the Department of Health.
“I can understand Monitor coming in and saying ‘you’ve got to sort your finance out or governance out’, but do we really need to go once a month to teacher (Monitor) and say ‘this is how we are doing’?
“Do we really need to spend large amounts of money on external support at the behest of Monitor when we have people capable who are executive directors, and non-executive directors are making sure things happen?
“And why are hospitals concentrating on cost-cutting and cost saving?
“Because that’s what Monitor requires and what the Department of Health is requiring.
“Whether you are in deficit or not, you still have to find five per cent (of savings) a year.”
According to Mr Saunders, this over-powerful and meddlesome ‘State’ control has fostered a culture in which trust managers focus on money and targets rather than care and its quality – all of which appears to bear striking similarities to the shifting sands on which Stafford’s crumbling edifice was built.
Francis’s seminal report is designed to prevent such a tragedy from happening again.
But whether or not it will tackle the structural problems highlighted by Mr Saunders remains to be seen.
As to changing other elements of the NHS’s culture, Mr Saunders alighted on the same topic mentioned by the Prime Minister in his initial reaction to the Francis report.
“More concentration should be placed on the personality being appointed or chosen for nursing rather than their educational achievements,” he said.
Compassion, he indicated, was not awarded with a degree but was innate.
The virtue was certainly lost at Stafford and appears in short supply elsewhere. Only time will tell if it can be recovered.