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Reviews / 2013

Statutory inquiryPublishedAcute careEngland

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry

Sir Robert Francis KC · work from 2010 · published 2013

What this was

Statutory public inquiry into the suffering of patients at Stafford Hospital. It described a culture that put the organisation's reputation and national targets ahead of patients, and a regulatory system that did not stop it. The inquiry made 290 recommendations.

Why it sits in the hub

Francis is the reference inquiry of the modern NHS. Duty of candour, fit and proper persons, Freedom to Speak Up and a tougher CQC all came from it. Later inquiries test whether those reforms changed what patients experience.

Findings

  1. Finding 1

    Patients were left unattended, unheard and harmed while the trust pursued foundation trust status.

    Culture and conductLeadership and boardsListening to patients and families

  2. Finding 2

    The board lacked insight, and commissioners, regulators and the wider system accepted reassurance.

    Data and early warningLeadership and boardsRegulation and oversight

  3. Finding 3

    Staff who raised concerns were not protected, and complaints were not a source of learning.

    Complaints and redressSpeaking up

Recommendations in this hub

The source reports 290 recommendations or essential actions. The notes below are a paraphrase, not the official text.

  1. 1AcceptedGovernment

    Put a statutory duty of candour on organisations when patients are harmed.

    A statutory duty of candour for providers followed. Inquiries continue to find it poorly practised. Thirlwall asked for an individual duty on managers.

    Candour
  2. 2Partly doneGovernment and CQC

    Set fundamental standards of care and make serious failure enforceable.

    Regulation and oversight
  3. 3Partly doneGovernment

    Apply a fit and proper person test to NHS directors.

    The test was introduced, reviewed by Kark in 2019, and is still being argued over in 2026.

    Accountability of managersLeadership and boards
  4. 4Partly doneNHS providers

    Make openness the default, and protect staff who speak up.

    Freedom to Speak Up guardians followed in 2015. Staff survey results cited to Thirlwall still show fear of detriment.

    Culture and conductSpeaking up
  5. 5Partly doneNHS providers

    Treat complaints as a way the organisation learns, with board ownership.

    Complaints and redressLearning from harm