It is 4000 pages long, Robert Francis QC's final report of his inquiry into the shortcomings of the Mid Staffordshire NHS Foundation Trust. Its findings, I gather, make more than disturbing reading. The one positive reaction I had from hearing and reading news reports was to be glad that Mr Francis had not entered the populist "name and shame" game. Instead he had looked at the endemic institutional reasons that such widespread deficient care had been able to take place.
In his accompanying letter to the Secretary of State, he outlined some.
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 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.
Scapegoating is such an easy game to play. One can understand why aggrieved parties should want a scalp. But it is a deeply primitive and unattractive instinct. One only has to remember the hue and cry which led to Ed Balls shamefully ensuring the unfair dismissal of Sharon Shoesmith, Haringey's head of children's services, after the Baby P affair to see an egregious example of the sort of thing. By and large those who go into the caring professions do so for the right reasons. When they fail, there are almost certainly reasons beyond themselves to blame, such as time restraints, staff shortages and multi-agency involvement.
Robert Francis is to be congratulated in not falling into the trap of blaming individuals or denigrating professionals. It's to be hoped that his report sets a trend - and that the media and lawyers do not pursue a witch-hunt.