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Friday, 8th February 2013

UK: Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis Inquiry)

Source: Mid Staffordshire NHS Foundation Trust Public Inquiry (UK)

From Letter to the Secretary of State:

The report has identified numerous warning signs which cumulatively, or in some cases singly, could and should have alerted the system to the problems developing at the Trust. That they did not has a number of causes, among them:

A culture focused on doing the system’s business – not that of the patients;
An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern;
Standards and methods of measuring compliance which did not focus on the effect of a service on patients;
Too great a degree of tolerance of poor standards and of risk to patients;
A failure of communication between the many agencies to share their knowledge of concerns;
Assumptions that monitoring, performance management or intervention was the responsibility of someone else;
A failure to tackle challenges to the building up of a positive culture, in nursing in particular but also within the medical profession;
A failure to appreciate until recently the risk of disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation.

+ Executive Summary (PDF; 914 KB)

+ Volume 1 (PDF; 4.2 MB)

+ Volume 2 (PDF; 3.8 MB)

+ Volume 3 (PDF; 2.9 MB)


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Having begun his career in academic libraries, Adrian Janes has subsequently worked extensively in public libraries, chiefly in enquiry work as an Information Services librarian. In this role he has had particular responsibility for information from both the UK Government and the European Union. He wrote a detailed report on sources for the latter which was published by FreePint in 2007, and has contributed articles to FreePint and ResourceShelf. He is involved in training in information literacy and the use of online reference resources.

A Contributing Editor to DocuTicker, he also write reviews for Pennyblackmusic.

Adrian can be reached at adrian.janes@freepint.com

More articles by Adrian Janes »



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