Stafford Hospital report: As it happened
Key Points
- The public inquiry into the failings at Stafford Hospital - one of the biggest scandals in the history of the NHS - has called for a change in NHS culture.
- Inquiry head Robert Francis says system 'put corporate self-interest and cost control ahead of patients and their safety.'
- PM David Cameron says what happened at the hospital was 'truly dreadful' and promises a tougher inspection regime
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Welcome to our coverage of the publication of the public inquiry - chaired by Robert Francis QC - into failings at Stafford Hospital. From previous inquiries, it is already known that many patients died needlessly at the hospital between 2005 and 2008, because of poor care.
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The inquiry, which heard from 160 witnesses between November 2010 and December 2011, has looked at why senior NHS managers and regulators failed to pick up on the abuse and neglect that contributed to hundreds of needless deaths.
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Our Q&A details what happened at Stafford Hospital and gives details of four previous major investigations into the scandal.
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Julie Bailey, right, of the campaign group Cure the NHS, whose 86-year-old mother Bella died while she was a patient at Stafford Hospital, is among those at the Queen Elizabeth II Conference Centre, central London, to read the report.
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1110: Adam Brimelow, BBC correspondent
tweets: Government planning chief inspector of hospitals to ensure trusts focus on compassion and a caring environment.
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The BBC's Dominic Hughes says staff at Stafford are poised for Mr Francis' report into why the scandal that enveloped this hospital five years ago was allowed to unfold. He says that, while the report will throw the spotlight on to the hospital once more, this is now an issue that has implications across the NHS in England.
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The BBC's Nick Triggle says that, in the years leading up to 2008, receptionists were left to decide which patients to treat, inexperienced doctors were put in charge of critically ill patients and nurses were not trained how to use vital equipment.
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While staff working there were part of professional bodies, who pride themselves for putting patients first, the shocking standards were allowed to continue for years, BBC's Nick Triggle adds
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1129: Linda Tempest, Bognor Regis, England
emails: Don't think this hospital is an exception - this has been going on in our hospitals for years. The government needs to send teams unannounced into every hospital to check up on how patients are treated. You don't need to have qualifications to see that food and water are being left out of patients' reach and that they are not being helped to eat and drink.
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Robert Francis QC is about to present his findings into failings of care at Stafford Hospital, at the Queen Elizabeth II Conference Centre. Prime Minister David Cameron will give his response in a statement to the Commons later.
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1133: Breaking News
There needs to be a "fundamental change" in the culture of the NHS to ensure patients are cared for properly, the public inquiry finds. The conclusion by the Francis inquiry comes after a £13m investigation into the Stafford Hospital scandal.
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1135: Breaking News
While it is well-known the trust management ignored patients' complaints, local GPs and MPs also failed to speak up for them, the inquiry said. The local primary care trust and regional health authority were too quick to trust the hospital's management and national regulators were not challenging enough.
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Christopher Langstone, Lancashire, UK
emails: A public enquiry, intervention by CQC, introducing inspectors, rules and regulations etc. is no solution. We only need a responsible nurse to supervise every hospital ward. We used to have them - they were called "Matrons".
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The Royal College of Nursing is also highlighted for not doing enough to support its members who were trying to raise concerns. The Department of Health was also criticised for being too "remote" and embarking on "counterproductive" reorganisations.
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This inquiry says the failings went from the top to the bottom of the NHS. The 1,781-page report catalogues missed opportunities at every turn - and says the findings still have relevance today four years after they first came to light in a 2009 report by the Healthcare Commission.
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The report says the failings created a culture where the patient was not put first. But the inquiry - chaired by Robert Francis QC - says the change needed does not require further reform.
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The report urges everyone from "porters and cleaners to the secretary of state" to work together to change the culture.
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1143: Robert Heath, Cannock, Staffs, UK
emails: I understand that mismanagement led to some severe problems at Stafford, but I would like to put an alternative picture. Between 2006 and 2008 I had 3 operations at Stafford which included a 10 day period in intensive care. The care I received was excellent and the staff were very caring throughout. I am now back to full health thanks entirely to the skill and care of the staff at Stafford.
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Robert Francis QC tells reporters at a press conference the story was one of "appalling and unnecessary suffering of hundreds of people" and that he has made 290 recommendations "designed to change the culture and make sure patients come first".
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1147: @PlatoSays
tweets: If there aren't criminal prosecutions for the appalling abuse at #Stafford - we've all been cheated.
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1148: Bill Manuel, Richmond
emails: One needs to realise this poor outcome has been driven by the Governments ridiculous approach to target setting and report generation... The cost-cutting and target-chasing culture lays firmly at the Government's's feet and they need to take some responsibility for the culture they are driving.
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The report's recommendations include the merger of the regulation of care into one body - two are currently involved. It calls for senior managers to be given a code of conduct and for the ability to disqualify them if they are not fit to hold such positions.
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Other recommendations include one that hiding information about poor care be made a criminal offence. And it calls for a statutory obligation on doctors and nurses "for a duty of candour so they are open with patients about mistakes".
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Mr Francis has also recommended an "increased focus on compassion in the recruitment, training and education of nurses, including an aptitude test for new recruits and regular checks of competence as is being rolled out for doctors".
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1151: BBC's Jane Dreaper @janedreaper
tweets: #Francis statement v strong: public trust in NHS betrayed by institutional culture
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In a letter to Health Secretary Jeremy Hunt, inquiry head Robert Francis says: "A system which ought to have picked up and dealt with a deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system."
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He adds that Stafford was therefore "not an event of such rarity or improbability that it would be safe to assume that it has not been and will not be repeated, or that the risk of a recurrence was so low that major preventative measures would be disproportionate".
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1152: Anon, Burton On Trent
emails: As a A/E Nurse I can tell you this a problem throughout the NHS. For many years targets have steered patient care; hitting targets missing the point. This problem has been going on for years... Stafford is the tip of the Ice Berg many other trusts will be watching feeling very nervous.
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Mr Francis says the public "is unlikely to have confidence that another Stafford does not exist, in the absence of being convincingly persuaded that sufficient change has taken place".
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And Mr Francis says "the consequences for patients are such that it would be quite wrong to use a belief that it was unique or very rare to justify inaction".
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1156: Boris, Ilminster, Somerset
emails: This is not a one off in one institution. I have both seen and been on the other end of bad hospital care. I had to have spinal surgery and wasn't allowed to sit up for two days following the operation, food was left out of reach, it took over an hour for healthcare staff to answer my alarm when I needed to use the bathroom and they didn't clean the sheets, bed or the ward in the entire 8 days of my stay.
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Inquiry head Robert Francis says there should be a "zero tolerance" approach to poor standards of NHS care. Hospitals that failed to provide "a fundamental standard" of care should be forced to close, he adds.
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1201: David James, Oxford, UK
emails: Results of the report yet to be revealed and there clearly was a total failure of management both professionally and corporately at Staffordshire which has not been properly addressed via a transparent disciplinary process.... There are issues and the focus on financial performance placed on the Trust by the SHA and Monitor the regulator has to be recognised. But good work is done and continues to be done by the NHS across England
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1201: Breaking News
Hundreds of patients at the hospital "were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety", Inquiry head Robert Francis tells journalists.
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1204: John Bell, Stafford, UK
emails: I am finding all this reporting a little difficult. Have being recently diagnosed with Cancer, I have received an amazing level of care from the Oncology and Haematology team of Stafford Hospital. It is such a shame that the whole hospital must be tarnished with the same brush. I would like to express my personal thanks to them publicly.
John Bell, Stafford
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Inquiry head Robert Francis calls at the press conference for "a patient-centred culture, no tolerance of non-compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership, caring compassionate nursing, and useful and accurate information about services".
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Meanwhile, Labour's Sadiq Khan has said the conclusions of the Francis report are "shocking" and there are "no excuses" for what happened.
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Shadow justice secretary Mr Khan defended the last government's record on the NHS and its spending on hiring more doctors and nurses. But Tory Michael Fallon said former Labour ministers should apologise if their "target-obsessed culture" was found to have contributed to the hospital's failings.
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1210: Denise Earle, Braintree, Essex, UK
emails: Stafford Hospital is the worst in the Country. Unfortunately, my family lived in the hospital catchment area. In 2006 my father died in that hospital.
My mother was treated in there several times over the last six years and I have appalling correspondence with senior people at the hospital which still confirms that hospital is not running efficiently. These include her being left for hours in her own faeces and losing her notes following breast cancer surgery. My mother died a few weeks ago in Walsall Manor hospital (after we refused to allow her back to Stafford Hospital) and the staff there were completely dedicated to the care of my mother and could not be faulted.
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1213: John Dyer @JohnCharlesDyer
tweets: I hope the genuine lessons of #Stafford isn't lost in the chorus of "I told you so" all sides #NHS
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1214: Angie Singh, Devizes, England
emails: : It's a relief to see the whistle being blown on appalling management in the NHS. However, it is a mistake to imagine that Stafford stands alone - this situation is widespread and extends to mental health as well as physical.
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1215: Juliet Brough @belledechocolat
tweets: Every nurse, doctor, health care assistant, porter etc, should ask themselves 'would I want my mum to be treated like this?' #Stafford
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Antony Sumara, @zemba Chief Executive of Mid Staffordshire NHS Foundation Trust from 2009 to 2011, tweets: There were failings from the top to the bottom if the NHS but the Board were to blame. #francis. Yup
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1219: Simon, Walton-on-Thames, Surrey, UK
emails: I fully understand the nature of this report and of the terrible things that happened at Stafford hospital. But I also want to say that there are good people who work and care at this hospital...
My mother was treated well by doctors, and cared for by the nursing staff. I have mixed emotions about this news story... But my reason for sending this story to you is that not everyone at this hospital lacks compassion, skill and knowledge to treat people.
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1222: William Quinn @Wilquin86
tweets: I was a patient at #stafford hospital and lived. Didnt realise i was that lucky to survive!William Quinn @Wilquin86
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Law firm Leigh Day, which represented 120 victims and their families who suffered abuse at the hospital, welcomes the recommendations in a statement. says they must be brought in "quickly to prevent the abuse which we as lawyers are still witnessing".
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1223: Elaine, Burntwood, UK
emails: Doesn't anyone care what all this furore is doing to the current workforce at Stafford - mistakes may have been made but I am sure they have learnt from them and I know from personal experience that the staff there give nothing but 100% even though resources are stretched to the limit! We should be proud of our NHS and the workforce who save lives everyday!!
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1223: Dr Alexander Burnfield, Stockbridge, Hampshire, UK
emails: Having worked in the NHS from 1968 to 1996 I am particularly distressed by the way it has turned out. It was a kind and friendly place and we spent as much time and money on our patients as they needed. Politicians were not interested and we had never heard of managers until the late 80s. Doctors and Nurses ran the service and we had never heard the word "audit".
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Julie Bailey, whose mother Bella, 86, died at Stafford Hospital, has called for resignations at the top of the NHS. Ms Bailey, of campaign group Cure the NHS, told reporters outside the Queen Elizabeth II Conference Centre: "We are going nowhere. We have lost hundreds of lives within the NHS, we want accountability - we owe that to the loved ones we have lost."
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The group Action Against Medical Accidents says the government "must now accept the recommendation for a legal duty of candour which would represent the biggest advance in patient safety and patients' rights in the history of the NHS". It adds: "So far they have fiercely resisted this."
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1233: Ciara Mahoney
tweets: The Stafford Hospital Enquiry, yes the failings are awful, but how can they work effectively with so many budget cuts and job losses
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1247: Breaking News
David Cameron says what happened at Stafford hospital "was not just wrong; it was truly dreadful". He promises immediate inspections after complaints and possible suspensions.
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Mr Cameron tells the Commons "what happened between 2005 and 2009 was not just wrong, it was truly dreadful - hundreds of people suffered from the most appalling neglect and mistreatment".
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Mr Cameron says some patients were forced to drink water from flower vases. "Many were given the wrong medication, were treated roughly or left to wet themselves and lie in urine for days," he says.
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1239: Sam in London
emails: I had the worst experiences of my life as a patient in the NHS. The overall culture is that the patient does not come first. Much more stringent recruitment process needed. A whole culture change whereby the patient always comes first is needed.
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TH in Leeds
emails: We need to have a standard minimum required level of nursing staff defined for every ward nationally. Hospitals need to operate 24/7 or at least 7 days a week. There's only skeleton staff over the weekend. It's ridiculous that patients have to wait until the weekend is over before certain tests and procedures can be done because staff are off...This happens all the time.
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1241: Simon Pilkington in Shrewsbury
emails: I had a stroke on May 5th 2010 that was never scanned at Stafford to confirm, but I was discharged from A&E as suffering a headache despite being taken there by ambulance. Two days later I was scanned at Stafford and the bleed was confirmed. I was treated well by all staff on the second visit except for one very poor night team indeed where they just wanted a quiet night and were not attentive. When transferred to New Cross at Wolverhampton, they were excellent in their care and attention and cannot be praised enough.
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Mr Cameron apologises "to the families of all those who suffered for the way the system allowed this abuse to go on for so long".
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1245: Linda Davis in Staffordshire
emails: My mother died at Stafford in 2007 and my family and I will never forgive ourselves for not doing more in complaining, in the way she was treated. She walked into Stafford Hospital but never came out again. There were times when she begged us to let her come home.
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1245: Linda Davis continues
One day we came in to find her face all bruised, only to be told she had fallen. No one seemed to know how. Another time we came in to find she had diarrhoea but no one attended to her. My brother had to take her to the toilet and clean her up.
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In response to the report, Mr Cameron says that, where a significant proportion of staff and patients raise concerns, immediate inspection will take place and the suspension of the board may follow.
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1247: Lisa Ward in Market Drayton
emails: I was taken from work to Stafford Hospital in 2005 with a suspected miscarriage. After a scan I was told that my pregnancy was not viable and that I had indeed miscarried. I was booked in for the following day for a D & C. I considered this overnight and decided to go to my own GP who referred me to the North Staffs Hospital. I went on to have a normal pregnancy and gave birth to my son Ben - now seven. I often go cold at the thought of not having him - something that could have so easily happened.
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Mr Cameron says there will be a new hospital inspection regime which examines the quality of care and makes a clear and publicly-available judgment on it. He announces the new role of chief inspector of hospitals.
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Mr Cameron says there are three fundamental problems with the culture of the NHS - a focus on finances and figures at the expense of patient care, a lack of accountability, and complacency.
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1253: Phil Hodson in Cannock
tweets: Can't believe people can question things in Stafford hospital report unfortunately I know first hand how bad it was #shameful
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1253: Tim Tantram
tweets: Stafford Hospital isn't all bad! They have lots of superb staff who delivered my son in testing circumstances 6 days ago! #MidStaffs #NHS
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Leader of the opposition Ed Miliband says what happened at Stafford was "not typical" of the NHS. Every day, the "vast majority" of NHS staff deliver great care to patients, he says.
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Mr Miliband says NHS staff were "as horrified as all of us by what happened". He adds: "We on this side are truly sorry for what happened. What happened has no place at any NHS hospital."
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The Patients Association hails "a watershed moment for our health service". But it says there is "a lot of blame to go around for what happened in Stafford - unfortunately too many people have escaped genuine accountability".
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1259: Patrick Imrie from Stone, Staffordshire
emails: I had a heart attack in 2007. Care on the intensive care ward was good. In the recovery ward care was less good. In a ward where rest was important, a patient from a medical ward was put in the ward who was so confused that sleep was very difficult. My wife and I were promised an advisory video - the wrong video was put in the machine... causing us a lot of distress. When being moved by ambulance to North Staffs Hospital the driver was given the wrong postcode and I was taken to a caravan park up the M6 north of Newcastle Under Lyme.
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1250: Breaking News
David Cameron confirms that a new post of Chief Inspector of Hospitals is being created from the autumn.
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The Royal College of Nursing, described by inquiry head Robert Francis QC as having been "ineffective" at Stafford, says "appalling care cannot be tolerated and everything should be done to ensure that it does not happen again". It says it is "acutely aware that it has real lessons to learn from how it supported members locally at Mid Staffs".
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1304: TH in Peterborough
emails: How many senior managers and boards are reading this thinking 'there but for the grace of god, go I ?' I'm sure there are plenty of Trusts that can see similarities with many of the individual failings from the report, but are thankful that they have not been subjected to the same scrutiny as Stafford. It's time for all of us that work in the NHS to wake up and take notice - it is simply not acceptable to deliver or witness poor standards of care.
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Mr Cameron earlier told MPs hospital inspections should examine "whether a hospital is clean, safe and caring, rather than just an exercise in bureaucratic box-ticking". He said he had ordered an immediate investigation into hospitals with the highest mortality rates.
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He said changes would be made so that the suspension of trust boards could by triggered by failures in care and not just financial failings - as is currently the case.
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1312: Alex Skrypnik in London
emails: Being originally from Ukraine, I have been living in the UK for the last 12 years and I must admit that I have never seen worse health service than here, in the UK. The NHS budget is comparable to a Eastern European country's budget, but yet the services provided are completely inadequate, despite the fact that facilities in some areas are best of the best.
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The Royal College of Midwives says its members are often "petrified" about whistleblowing and welcomes Robert Francis QC's recommendation of a duty of candour. "NHS staff must never again be afraid to raise concerns about standards of NHS care", it says.
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1316: David Fleet in Cannock
emails: Stafford Hospital kept me fully informed as to my condition and treatment throughout my stay and treated me with respect and sympathy when I was informed that I needed a triple bypass operation in 2005. I had nothing but praise for the hospital when I was admitted following a heart attack. The team in the cardiac care ward were fantastic, as were the members of the cardiac rehabilitation team following my bypass operation at another hospital.
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1318: Peter Ross in Stafford
emails: Stafford Hospital clearly has problems, indeed my own mother had a bad experience there a couple of years ago, but it is still a hospital needed by the local community. Stafford Hospital has financial problems as well as problems with care and there is a real danger that it will be forced to close its doors, meaning people will have to travel to Stoke or Wolverhampton. The hospital has been guilty of some appalling care, but it can't improve if it no longer exists.
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Macmillan Cancer Support says the report exposes "a sub-culture within parts of the NHS which time and again severely compromises patient safety and quality of care". It adds that individuals working in hospitals "must ensure no patient ever again experiences the appalling care that has been revealed at Mid-Staffordshire".
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1319: Kelly in Stafford
emails: My mother was taken to A & E, Stafford in March 2007 after a fall. She was practically unconscious for the whole time she was there. The doctor sent her home saying there was nothing wrong with her even though she had a very badly bruised head from the fall. She wasn't given a scan (which we were told would have been given routinely at another nearby hospital) and we were left to try and carry her back to the car. A week later she was finally admitted and diagnosed with a brain tumour. During the week she was looked after in the Emergency Assessment Unit at Stafford, she received terrible care.
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Patients suffered as a result of a Whitehall failure to ensure "the right number of staff with the right mix of skills on hospital wards", Unison union says. It warns that, in implementing cuts, the government is "in the process of recreating across the whole of the NHS the dangerous financial pressures that surrounded Mid-Staffs".
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1324: Josie George
tweets: Just want to say, Stafford Hospital have always treated me superbly. All my experiences are of hard working, efficient, caring staff.
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Mike Farrar, chief executive of the NHS Confederation - which represents all the organisations providing NHS care - says "today is a day I genuinely feel shame".
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1327: Hannah in Stafford
emails: Speaking with friends today, we all agree that Stafford Hospital has treated us all well, particularly the maternity services. I really don't want to give birth anywhere else and I'm due in March. I hope these historical issues don't close the hospital we have today.
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1327: Anon
emails: My wife currently works as a Nurse at Stafford Hospital, she is ashamed to tell people where she works and what she does, and feels her personal security is at risk. She is a dedicated, loving and caring person who is now going to leave the profession altogether.
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1330: Rhonda Smith in Hampshire
emails: Regulation and inspection are important, but on their own will not work. What is needed is a shift in attitude in 'culture' from revenue to relationships. Care is not about ticking off a list of tasks but engaging with every single patient to ensure their moral and legal right to safe care appropriate to them as individuals is delivered. Patient-centred care will only become a reality if that shift happens - and when all NHS staff from chief executive to healthcare assistant embrace and adopt that shift.
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The public inquiry, chaired by Robert Francis QC, is the fifth inquiry into the higher than expected number of deaths at Stafford Hospital. Our timeline details the inquiries.
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1331: Matthew in Wolverhampton
emails: My girlfriend went into Stafford hospital for a minor operation in the day unit. After the operation she insisted she felt unwell, but it took them an additional five hours to realise she had internal bleeding, at which stage they rushed her back to theatre. She was lucky enough to avoid having to have a blood transfusion, but only by a couple of hours. Some staff were great, but the overall experience is one I never wish to experience again. It is far too easy to blame the government and budget cuts, people need to start taking responsibility for their own actions and stop playing the blame game.
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1331: Breaking News
The Mid Staffordshire NHS Foundation Trust apologises unreservedly for its failures and says the Francis report is "rightly damning" of the hospital's performance at the time.
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1333: Olivia Waggett
tweets: Stafford hospitals quality & care is amazing, so many improvements, not just my work but been a patient #standupforstaffordhospital #nhs
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1336: Anon
emails: As a nurse on the front line of services, all I am hearing is accountability and blame. Stop discussing who to blame and start making changes.
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The Royal College of Surgeons says the "catalogue of neglect, squalid bedside humiliation and unnecessary deaths" at Stafford is "beyond comprehension". National Voices, a coalition of 130 health and social care charities, meanwhile, says managers in the NHS must "develop systems of feedback that are comprehensive, working at all levels of the system and enabling staff to respond quickly".
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Derek Locke, whose daughter Jane died after being treated at Stafford in 2006, says he would be happy if "only half" of Robert Francis' 290 recommendations were implemented.
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Rebecca in Hereford
emails: My father had excellent care from surgeons at Stafford, but once described another patient, who couldn't get out of bed, in desperate need of a nurse so he could relieve himself. Dad struggled to walk to a nurses station where staff were taking a break, and were not happy to be disturbed. Having said this, there were some exemplary nurses there who went above and beyond to attend to dad's needs, even waiting after hours to see he was OK following urgent surgery.
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Paul in Uttoxeter
emails: My mother in her 80's attended and was admitted to Stafford Hospital on a number of occasions between 2004 and 2007. She was admitted for observation between Christmas and new year 2004/5 it was just a horror, mixed ward, mixed ages, NO cleaning at all over the several days she was there before she was transferred to a ward. I wrote an email complaining, but of course I now now they were just ignored.
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1341: Anon in Blackpool
emails: I have personally experienced dreadful effects of the cuts in funding at the hospital where I work. I have read the reports of the appalling neglect at Stafford and can see the potential for the same situation developing throughout the NHS. It is heartbreaking to work in a caring profession and not be able to provide the care that all patients deserve.
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Stafford Hospital is now a changed place, Mid-Staffordshire NHS Foundation Trust chief executive Lyn Hill-Tout says. "We have learnt the hard way," she says.
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Ms Hill-Tout adds: "We have learned from that experience and, through listening to the inquiry witnesses, our patients, staff and local community, we try every day to continue to improve the care we provide to our patients."
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That concludes our live text coverage of the publication of the public inquiry into failings at Stafford Hospital. You can read more in our main news story.
~RS~q~RS~~RS~z~RS~36~RS~)
