Published Tue, 2011-11-22 13:35; updated 34 weeks ago.
The chairman of the Mid Staffordshire Public Inquiry has been urged to reconvene in a year's time to ensure "political inertia" has not prevented his recommendations from "taking flight".
On the opening day of the year-long Inquiry's closing submissions, the independent charity Action against Medical Accidents (AvMA) finished a damning summary of all that went wrong at Stafford Hospital by urging Robert Francis QC to ensure that, this time, lessons were learnt.
"You have previously been involved with a number of mental health inquiries and you will have seen how often the same messages come out of those inquiries, again and again, implying, clearly, that lessons have not been learnt," said Peter Skelton for the AvMA. "You will have seen the political inertia that greeted at least some of the recommendations that Dame Janet Smith made in the Shipman Inquiry, something that she is talking about quite a lot these days.
"You will no doubt be very keen to ensure that your inquiry is of real benefit, that it leads to implementation, and you will be acutely aware of the fact that there are very serious and sweeping reforms already in the pipeline, that there is a danger that your reforms, however carefully wrought, however backed by the evidence, however supported by the organisations who you have brought into your Inquiry, will not gain the political momentum they need to take flight.
"To that end, AvMA urges you to follow you to follow Lord Bichard's model and at the very least reconvene your inquiry in 12 months' time to see what the Government has done in response."
The AvMA's submission was followed by a closing statement from pressure group Cure the NHS, which was set up in 2008 by cafe owner Julie Bailey whose mother, Bella, was one of hundreds of patients who are thought to have died needlessly at Stafford Hospital between 2005 and 2009.
Jeremy Hyam, on behalf of Cure, also delivered a harsh assessment of the roles played by regulators and supervisory organisations that allowed the situation at Stafford to develop and continue for so long.
He also condemned a healthcare culture that sought to "deny and defend" rather than be "open and self-critical" when problems surfaced.
"At the heart of this Inquiry is the question: why such serious concerns, which were obvious to those on the front line, and obvious to the patients and relatives who made complaints, were not picked up by those who were responsible for monitoring, supervising performance managing and regulating the trust?" he asked.
"There are also deeper questions. What is it about the culture of NHS hospital care that created a system where the voice of the individual patient or nurse is drowned out by political pressure, targets and/or processes? A culture that seeks to deny and defend, rather than be open and self-critical, whose first response to criticism is to seek an alternative explanation, rather than investigate the most likely and most serious cause or causes, and that fears to empower patients and front line workers in hospital lest their decisions on how to run a ward or a waiting list are incompatible with the latest political direction?"
- The Inquiry resumed on Tuesday, 22 November