Repeat after me: “Mid Staffordshire”

Which of the following is the odd one out, and why?

• Alder Hey (retention of children’s organs)

• Bristol (children’s heart surgery)

• Shipman (serial killer)

• Mid Staffordshire (emergency services)

The right answer is Mid Staffordshire. Score one point if you selected it because it’s a 21st century scandal, whereas the other three date from the previous century. Score double if you selected it because you hardly remember any details 10 months after it was reported, whereas you aren’t allowed to forget the other three.

The short term amnesia concerning Mid Staffordshire is particularly curious if you compare the death tolls associated with the scandals: Alder Hey (0), Bristol (30 to 35), Shipman (probably 250), Mid Staffordshire (400 to 1200). The nature of the ensuing inquiries may be relevant here. The 20th century inquiries were usually fronted by the good and the great, went on for years, and generated reams of finely crafted recommendations. (Janet Smith’s six reports on Harold Shipman, four years in the making, ran to more than 2500 pages.)

By contrast, Investigation into Mid Staffordshire NHS Foundation Trust ran to a meagre 172 pages and came with an initial assurance that it was likely to be the first and last official word on the events under investigation (other than quick reviews of the present state of emergency services at the trust and why the failings weren’t detected earlier). In his House of Commons statement the then health secretary for England, Alan Johnson, rejected calls for a public inquiry. What had happened “was an absolute exception.” In July the government partly relented (more of that later).

Medical journals could have done more to bring the scandal to doctors’ attention. Compared with the 20th century medical scandals, the BMJ’s coverage of Mid Staffordshire was relatively muted: a single short news story covered the report’s findings, followed up by an editorial two months later (BMJ 2009;338:b1141, doi:10.1136/bmj.b1141; 2009;338:b1958, doi:10.1136/bmj.b1958). Other than publishing two letters about data interpretation the Lancet didn’t mention it at all.

In case you missed the report the first time round, here are two key paragraphs from the Healthcare Commission’s report:

“In the trust’s drive to become a foundation trust, it appears to have lost sight of its real priorities. The trust was galvanised into radical action by the imperative to save money and did not properly consider the effect of reductions in staff on the quality of care. It took a decision to significantly reduce staff without adequately assessing the consequences. Its strategic focus was on financial and business matters at a time when the quality of care of its patients admitted as emergencies was well below acceptable standards.”

And the second, a couple of pages earlier:

“It was clear from the minutes of the trust’s board that it became focused on promoting itself as an organisation, with considerable attention given to marketing and public relations. It lost sight of its responsibilities to deliver acceptable standards of care to all patients admitted to its facilities. It failed to pay sufficient regard to clinical leadership and to the experience and sensibilities of patients and their families.”

Is the trust really an “absolute exception”? I wonder.

Here are the lessons identified by the Healthcare Commission in 2007 from the outbreaks of Clostridium difficile that killed 33 people in Stoke Mandeville Hospital (part of Buckingham Hospitals NHS Trust) and 90 at the Maidstone and Tunbridge Wells NHS Trust:

“Both trusts had undergone difficult mergers, were preoccupied with finance, and had a demanding agenda for reconfiguration and PFI [private finance initiative], all of which consumed the time and effort of senior managers . . . Additionally, the impact of financial pressures was to reduce further already low numbers of nurses.”

Once we learn why things went astray at Basildon and Thurrock University Hospitals NHS Foundation Trust last year (BMJ 2009;339:b5129, 1 Dec, doi:10.1136/bmj.b5129) there should be enough material for a meta-inquiry into English medical scandals of the 21st century. My hunch is that it would find more similarities than differences among them.

Meanwhile, events at Mid Staffordshire between 2005 and 2008 are receiving a second look. Announced in July, an “ad hoc” inquiry is due to submit its report to the secretary of state by the end of the month (BMJ 2009;339:b3816, 15 Sep, doi:10.1136/bmj.b3816). It’s being held in private rather than in public, and unlike a statutory inquiry it cannot compel people to give evidence (in other words it’s a 21st century sort of inquiry to match a 21st century sort of medical scandal). In a uniquely modern twist there are no plans to share this report’s findings beyond the patients and staff involved.

It’s hard to know whether anything new could emerge from this inquiry, given its focus on ensuring that patients and their families have an opportunity to raise their concerns. “These experiences need to be properly aired if the local NHS is to learn and, in time, move on,” said the health secretary Andy Burnham, announcing the inquiry.

While we wish the healing process well, healthcare workers would be interested in the inquiry’s examination of what happened to safety incident reports filed by staff on the relevant wards. Of 515 such reports more than a third either reported inadequate staffing or attributed an incident to inadequate staffing.

A consultant at Stafford Hospital has already told the parliamentary health select committee that incident forms completed by a consultant colleague were downgraded to minor events by nurse managers without discussion or investigation. The Royal College of Nursing said that people thought that incident forms were ending up in black holes or wastepaper baskets (one nurse reportedly saw an incident form in a senior manager’s wastepaper basket.) Since then the government has wisely made it mandatory to report all safety incidents to the National Patient Safety Agency. The content of incident forms—and institutions’ responses to them—should be fertile territory for future inquiries.

For doctors lacking an appetite for the martyrdom that comes with whistleblowing the humble incident form might allow a sort of “whistleblowing lite.” It’s worth a try. Another common feature of all these scandals has been someone asking, “Why didn’t the doctors do more?”