, whose mother died in Stafford Hospital in 2007, started a campaign called Cure the NHS to demand changes to the hospital. She was supported by the Staffordshire Newsletter, but the Public and Patient Involvement Forum and the Governors of the Trust were defensive. The scandal came to national attention because of an investigation by the Healthcare Commission in 2008 into the operation of Stafford Hospital in Stafford, England. The commission was first alerted by the "apparently high mortality rates in patients admitted as emergencies". When the Mid StaffordshireNHS Foundation Trust, which is responsible for running the hospital, failed to provide what the commission considered an adequate explanation, a full-scale investigation was carried out between March and October 2008. Released in March 2009, the commission's report severely criticised the Foundation Trust's management and detailed the appalling conditions and inadequacies at the hospital. Many press reports suggested that because of the substandard care between 400 and 1200 more patients died between 2005 and 2008 than would be expected for the type of hospital, based on figures from a mortality model, but the final Healthcare Commission report concluded it would be misleading to link the inadequate care to a specific number or range of numbers of deaths. An independent 2008 study into hospital standardised mortality ratios found that this measure, as developed by the Dr Foster Unit at Imperial College, is prone to methodological bias, and that it was not credible to claim that variation in mortality ratios reflects differences in quality of care. In 2015, The Guardian amended an article from 2013:
...subsequent investigations into the poor care at Stafford hospital, including the two reports by Sir Robert Francis QC, said that this disputed estimate, which appeared only in a draft report from 2009 by the Healthcare commission and was based on mortality statistics, was an unreliable measure of avoidable deaths. The Francis report of February 2013 concluded that it would be unsafe to infer from these statistics that there was any particular number of avoidable or unnecessary deaths at the trust.
As a result, the trust's chief executive, Martin Yeates, was suspended, while its chairman, Toni Brisby, resigned. Both Prime Minister Gordon Brown and Health Secretary Alan Johnson apologised to those who suffered at the hospital. Also in response to the scandal, the mortality rates of all National Health Service hospitals have been made accessible on a website. It later emerged that a "compromise agreement" had been agreed with Martin Yeates whereby he left the NHS with a large sum of money. He did not give evidence at any of the enquiries, apparently because of health problems, but he was appointed to be Chief Executive of Impact Alcohol and Addiction Services in 2012. Some executives who had been responsible for the trust at the time received promotions within the health service and were loudly criticised. Cynthia Bower, who was from 2006 chief executive of NHS West Midlands, was recruited to run the Care Quality Commissionquango. Sir David Nicholson was in charge of the regional health authority responsible for the hospital at the height of the failings between 2005 and 2006. On 21 July 2009, the Secretary of State for Health, Andy Burnham, announced a further independent inquiry into care provided by Mid Staffordshire Foundation Trust. The generally critical inquiry report was published on 24 February 2010. The report made 18 local and national recommendations, including that the regulator, Monitor, de-authorise the Foundation Trust. Compensation payments averaging £11,000 were paid to some of the families involved. In February 2010, Burnham agreed to a further independent inquiry of the commissioning, supervisory and regulatory bodies for Foundation Trusts.
Public inquiry
In June 2010, the new government announced that a full public inquiry would be held. The inquiry began on 8 November 2010 chaired by Robert Francis QC, who had chaired the fourth inquiry which he had criticised for its narrow remit. The inquiry considered more than a million pages of previous evidence as well as hearing from witnesses. UK expert medical lawyers also offered their assistance to distraught and angry families who waited for proof that lessons had been learned. Many families of the victims felt that crucial questions have been left unanswered. The final report was published on 6 February 2013, making 290 recommendations. Academics at the University of Oxford and King's College London have criticised its recommendations to legally enforce a new duty of openness, transparency and candour amongst NHS staff, arguing that increasing 'micro-regulation' may produce serious unintended consequences. The revelations of the neglect to patients at Stafford hospital were widely considered to be deeply shocking by all sections of the mainstream UK press; for example, patients were left in their own urine by nurses.
Actions against nurses
The Nursing and Midwifery Council, the UK’s regulator of nurses and midwives, has held hearings about nurses working in the trust following allegations that they were not fit to practise. Acting to protect the public, the NMC has struck off from their register and suspended 2 nurses as a result of these hearings. This includes two nurses who falsified accident and emergency discharge times, two nurses involved in the death of a diabetic patient and a nurse who physically and verbally abused a dementia patient.
