A look back at the Stafford Hospital public inquiry

Health Correspondent Shaun Lintern looks back over nine months of explosive evidence at the public inquiry into the disaster at Stafford Hospital.

When a public inquiry was announced to investigate how the NHS could have failed patients at Stafford Hospital so badly, many questioned whether such a probe would reveal anyhing new.

Having been involved with the long-running saga of what happened at the troubled hospital for the past four years I wondered what we might learn from such a detailed investigation.

Even campaigners who battled for so long to get the inquiry created believed the wards at Stafford Hospital did not hide anymore secrets.

How wrong we all were.

Having sat through more than 100 days of shocking evidence and the often amazing testimony from over 150 witnesses I would question if even the Health Secretary Andrew Lansley knew what kind of a hornets nest he was stirring up when he asked Robert Francis QC to take a microscope to the NHS.

Far from focussing solely on the events at Stafford Hospital the inquiry has smashed open some of the dark corners of the National Health Service, exposing a rotten underbelly of ignorance, idiocy and downright incompetence by many of those trusted to ensure the NHS works for patients.

The inquiry has shed light on what many have suspected for years, a culture of bureaucracy running through the heart of the NHS with a dizzying array of bodies, agencies and organisations, many of whom fighting turfwars over their roles.

When it mattered most, these organisations have been shown to have failed in their single most important role - to protect patients.

Not a single witness who has appeared at the inquiry has avoided having to admit to some level of failing and having listened to the evidence it has been hard not to draw the conclusion that the NHS is fundamentally flawed.

But it is also important here to stress the fact the NHS treats over one million people every single day with nurses and doctors working 12 hours shifts or longer to care for the sick and injured.

The vast majority of patients receive good care from our health service and we should be proud of that fact.

But no matter how good the NHS is thousands of good stories do not and should never overshadow even just one bad story.

The NHS must approach its work with an aim to doing zero harm all the time.

We have seen a steady stream of organisations tell the inquiry they were unaware of crucial warning signs. Others knew there was a problem but failed to act or follow-up their concerns.

Even the Healthcare Commission, whose original investigation exposed the poor care at the hospital in 2009, was shown to have missed early signs with its regional office not even knowing an investigation was being carried out in 2008.

The way it assessed hospitals relied on NHS trusts being honest and the whole system was based on a process that were easy to manipulate.

The current watchdog the Care Quality Commission fared no better with its chief executive Cynthia Bower having to defend the organisation for gagging witnesses and for scrapping investigations.

Despite the inquiry hearing a lengthy list of warning signs missed by the West Midlands Strategic Health Authority Mrs Bower refused to accept there was a failure at the SHA when she was boss there also.

She did accept though that signs were not put together.

The inquiry has also heard from witnesses who never passed on their concerns including many doctors and nurses who have a professional duty to speak out.

Many witnesses didn't see it as their role to speak up or assumed other organisations were looking at problems when in fact no one was.

The inquiry has also brought to light harrowing details of exactly how dangerous the hospital was for some patients.

Its accident and emergency department at one stage in 2007 and 2008 had just one consultant, with no cover after 9pm at night and at weekends and bank holidays meaning seriously ill patients were being seen by junior doctors with no back-up.

A secret report, made public by the inquiry, also showed the hospital's surgery department as being "unsafe, and at times frankly dangerous."

The inquiry was also told how death rates at the trust were manipulated to hide the true extent of poor care.

Many of the problems at the hospital were sparked by a £10 million budget cut and a re-organisation of wards but the hospital was never challenged to defend this action or provide assurances the plan was safe for patients.

This happened despite a history of low staffing and funding problems at the hospital which were missed when the NHS underwent a major re-organisation in 2006.

Behind the catalogue of errors, misjudgements and mistakes was a hospital management who were pushed to get Foundation Trust status just months after being told it was two years away.

The inquiry has heard evidece that the then Labour Government wanted a push on getting hospitals through the Foundation Trust process with former health secretary Andy Burnham rubber-stamping the hospital's bid despite civil servants describing the hospital as a "borderline" application.

A repeated theme at the inquiry, held in Stafford's civic centre, has been the damage caused to the NHS by the repeated chaos of changes to its structure by successive governments which damage morale and create confusion.

That will be a particular concern of chairman Robert Francis when he draws up his report at the end of the inquiry in light of the coalition Government's massive health service reforms which are the most ambitious the service has seen since its launch 63 years ago.

All of this is before the inquiry begins hearing evidence from the Department of Health in September when it is likely senior civil servants and ministers will be expected to give evidence.

Looking forward Mr Francis, who led an earlier secret inquiry, into the care at the hospital, will have to draw up a report aimed at making sure lessons from the catastrophe are learned.

He will have to tackle the gaps in regulation which allowed warning signs to go unchallenged and could look to create a single NHS regulator.

Whatever his recommendations the Government must make sure it is prepared to act on the findings and not let the report sit on a Whitehall shelf while patients suffer.