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Francis report demands ‘duty of candour’ laws

New laws requiring doctors and other health professionals to be open and truthful when mistakes have occurred have been recommended by the inquiry into failings at Mid Staffordshire NHS Trust.

The report, by Robert Francis QC, calls for a ‘duty of candour’ to be imposed on doctors to report incidents that have caused ‘death or serious injury’ as soon as possible.

It also recommends that it should become a criminal offence for a doctor to mislead a patient or relative about any harm that has been caused, lie to a regulator or a commissioner or obstruct anyone else from raising concerns.

Francis says too many consultants at Mid Staffs kept their heads down instead of speaking out when things went wrong and failed to take a lead in promoting change.

Prime minister David Cameron said medical regulators should explain why no one has been disciplined after the Francis Inquiry detailed years of abuses at two Stafford Hospitals as he apologised in Parliament for “appalling failures of care”.

The report itself did not name and shame any officials or doctors. It blamed an “insidious negative culture” for years of poor care between 2005 and 2009, including patients left unwashed, in soiled sheets and thirsty. It said there should be no scapegoating of any individuals or organisations.

Examining the role of the GMC, the report says an absence of referrals from professionals may have been due to the unhealthy culture at the trust. It recommends that the GMC now develops its capacity to examine and investigate concerns even where no individual has been reported to it.

Francis also scrutinises the system of regulation and oversight of medical training and education in place between 2005 and 2009 which also failed to detect any concerns about the trust.

The former Postgraduate Medical Education and Training Board, GMC and deanery wide reviews focused only on deanery systems of quality management and failed to consider patient safety standards.

When concerns were raised about inappropriate pressure or bullying by staff towards trainees these were not followed up or investigated.

The report sets out a raft of recommendations for ensuring that medical education and training systems in future enhance patient safety. It says students and trainees should not be placed in hospitals which do not comply with patient safety standards.

Another of the 290 recommendations directly impacting on doctors is a requirement for all healthcare provider organisations to develop and publish real time information on the performance of their consultants and specialist teams in relation to mortality, morbidity, outcome and patient satisfaction, and on the performance of each team and their services against a set of fundamental standards.

Following publication of the report Cameron announced that NHS medical director Sir Bruce Keogh is to investigate trusts with high death rates and check that remedial action is being taken.

The first five trusts to be scrutinised will be Colchester Hospital University Foundation Trust, Tameside Hospital Foundation Trust, Blackpool Teaching Hospitals Foundation Trust, Basildon and Thurrock University Hospitals Foundation Trust and East Lancashire Hospitals Trust.

Cameron also announced that the Care Quality Commission is to appoint a new Chief Inspector of Hospitals to check whether hospitals are clean, safe and caring.

In a statement Francis said: “We need a patient centred culture, no tolerance of non-compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership and caring, compassionate nursing, and useful and accurate information about services.”

The profession’s response:

BMA chair of council, Dr Mark Porter: Despite all the regulations and guidance to help staff raise concerns, a climate of fear, bullying and harassment can stop clinicians from speaking out.

“Unless and until medical staff and management jointly promote the ethos that raising concerns is not only acceptable but a positive thing, the shadow of Mid Staffs will put us all into darkness. Doctors, along with other clinical staff, have a professional responsibility to show leadership in helping to change this culture. We must no longer accept the attitude that it is someone else’s job to worry about.”

The Academy of Medical Royal Colleges: “We believe that poor care is not everywhere in the NHS but has the potential to happen anywhere. Many doctors will have had experience of aspects of what happened at Mid Staffordshire. Within organisations which in overall terms provide a good standard of care there can be departments, wards or teams where standards fall below what is acceptable.”

Professor Norman Williams, President of the Royal College of Surgeons: “We are now preparing for the publication of surgeons’ results later this year and welcome the report’s commitment to the publication of proper outcome data which is publicly funded. The surgical profession believes this will help reduce mortality rates through greater scrutiny, drive down poor performance and ultimately empower patients.

“But there is still a long way to go. We are still concerned about a zealous pursuit of targets in some trusts to the detriment of quality of care, particularly around the focus on elective procedures in preference to urgent or emergency work. There is also fragmentation of care, as patients will sometimes see four or five doctors in a day due to the rules on working hours and shift patterns. We look forward to the government helping to overcome this issue and ensure that there is greater continuity of care and less disruption.”

GMC executive Niall Dickson: “We have investigated 42 doctors from Mid-Staffs and have sought to keep the inquiry updated on the progress of these cases. Twenty-two of the doctors have received formal letters from us advising them about their future conduct, one has accepted restrictions on their practice, and a further eight are subject to ongoing active investigation; four of whom are due to appear shortly before a public hearing. If they are found guilty, there will be sanctions including the possible loss of their registration.”

Sir Richard Thompson, president of the Royal College of Physicians: “Patient safety and quality improvement is a shared responsibility between healthcare professionals, managers and others working across the system. The RCP is committed to continuing our leadership role in ensuring doctors take responsibility for holistic care, not just diagnosis and treatment, and all care must be compassionate. Many of the Inquiry’s findings match those in Hospitals on the Edge? and we will incorporate the Inquiry’s recommendations into our Future Hospital Commission.”

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3 Responses to “Francis report demands ‘duty of candour’ laws”

  1. […] public inquiry into Mid-Staffordshire NHS Trust from 2005-2009, chaired by Robert Francis QC, found years of abuse […]

  2. Malcolm Morrison says:

    The Francis Report should provide a wake up call to ALL who work in the NHS – from the Secretary of Stae, down through all the layers of bureaucracy, to those working ‘one the front line’ – particularly ALL PROFESSIONALS who have contact with patients.

    The first DUTY of a doctor is to “do no harm”. It is already, and always has been, the duty of ANY doctor to ‘protect’ the patient; and, thus, report any behaviour by anybody that is putting a patient at risk – and this has been stated, repeatedly, by the GMC.

    Whistle-blowing has never been easy – but one’s professional DUTY should take precedence over possible personal attack. I recognise that, in many parts of the NHS, there has been a ‘hostile attitude’ towards any criticism from any quarter; and that, in some cases, there has been ‘bullying’ by both managers and, more to their discredit, some senior professional staff. However, if the whistle-blower has their facts right, they should not be ‘scared off’ because their ultimate ‘court of justice’ can be either the GMC or the ‘free press’.

    Retired Orthopod

  3. Whistler says:

    Scandals like this will occur more often in the future as the DOH is gagging doctors by preventing whistle blowing.

    Revalidation will require doctors to obtain positive annual employer appraisals and multi-source feedback from colleagues in order to renew their licence to practice. Doctors will therefore now be discouraged from whistle blowing and highlighting patient safety concerns as they will fear loosing their licence to practice medicine due to a negative employer appraisal or multi source feedback. Any kind of assurance that whistle blowers will be protected is unlikely to reassure doctors who will loose their livelihood if their licence to practice is not renewed due to such negative employer appraisals and feedback.

    As healthcare is being increasingly provided by cost cutting private employers, one can imagine the dangers to patients if doctors cannot highlight safety concerns for fear of loosing their licence to practice medicine because of the threat of a negative appraisal from a private sector employer.

    These doctor revalidation requirements must be scrapped to prevent future patients deaths and scandals such as those highlighted in the Francis Inquiry. The Francis Inquiry shows that dangerous policies were not changed by authorities despite being highlighted by staff and that this needs to change.

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