5c) Case Study 1: Mid Staffordshire NHS Foundation Trust Public Inquiry

Ethics, whether personal, professional, or within society, is and will forever be argued within every issue that we come across. The media highlights and expresses their opinions on most scandals that surface and from this we are expected to use our personal ethics to make our own conclusions on the subject. Of course it is important to remember that those working within the media will have their own opinions and marketing interests within their publishings. This being another ethical factor that has to be taken when deciding what goes wrong within societies ethical standards.

Reader 5 introduces us to examples of this. Case Study 1 discusses a scandal within a hospital where an argued unnecessary amount of patients died due to severe malpractice. The amount of ethical issues within this case is vast as not only the morals of the hospital staff needed to be addressed but also the higher management within the organisation who appeared to have overlooked the mistreatment of the patients.

After reading the case study I wanted to find more about the case and came accross the official website of the inquiry:

http://www.midstaffspublicinquiry.com/

Within this website you are able to research the full case including the evidence given, the inquiries costs, the series of reports that were made throughout the case and the final report which was published in 2013. From reading through some of the final report I was able to get more insight into what had been brought up in the case and the repercussions. I made note of key facts of the case so it was easier to analyse. From what I read in Robert Francis' report the reasons to blame for the misconduct were the following:

• Trust board didn't listen to patients or staffs needs or concerns.
• Managerial or Leadership Issues were not addressed.
• Misplaced focus of reaching national and financial targets were in the place of correct treatment of patients.
• Agencies, Commissioners and Regulators did not detect or turned a blind eye to the arising issues within the organisation.
• The NHS checking systems to avoid such incidents within the organisation were not followed.

Below I also took the List of warning signs and the personal stories from patients families from the final report to concentrate on the key facts of the case.

Warning Signs

• 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 ofa 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

Patient and Families Stories

•  Patients were left in excrement in soiled bed clothes for lengthy periods;
•  Assistance was not provided with feeding for patients who could not eat without help;
•  Water was left out of reach;
•  In spite of persistent requests for help, patients were not assisted in their toileting;
•  Wards and toilet facilities were left in a filthy condition;
•  Privacy and dignity, even in death, were denied;
•  Triage in A&E was undertaken by untrained staff;
•  Staff treated patients and those close to them with what appeared to be callous indifference.

The above examples of how the patients were mistreated already raises a huge amount of ethical arguments. When speaking to peers about this case, the opinion that each of our personal ethics or morals should not allow the sort of abuse these patients had been exposed to, without even needing any organisational ethical structure or guidance (which I discuss in a previous blog). In further discussion with others about the case I provided them with a brief amount of information, such as above, and asked them the series of questions recommended within Reader 5 about the case.

1. At Whose door do ethical principles lie?
2. Where do the limits for responsibility lie?
3. Are there any overlaps?
4. Wheres are the tensions?
5. How would these be resolved?

A few of the responses I got about the case during the discussion are as follows:

"Ethical principles lie with everyone. I think that as much as you can blame an organisation for failing, it is the individuals that should have the focus because at the end of the day, that can be the root of the problem which can spread even more widely. As long as individuals take responsibility for their own ethical actions, a lot of bad can be avoided."

"The responsibility lie with all of the above and the government. We should go back to having Matrons on every ward who oversee the running and patient care. These Matrons should then report back and what they say should be heeded to. No one should be left in this state of affairs, no human being. Everyone should have great  care and dignity given to them from entering to leaving the hospital. This is a humans moral and ethical right."

"Ethical principles lie with both higher authoritative figures and organisations but also with each individual. Although much blame can and should be placed on the organisations and agencies themselves it is the individuals within these systems that could have prevented such a tragic turn of events. As individuals we hold our own personal responsibilities and these should be considered and explored during the application process for these kinds of jobs. It is the higher authoritative figures responsibility to make sure the right kinds of people are employed for these roles to avoid mistreatment. Responsibility, therefore, lies with both the broader agencies and companies but also with each individual. There are slight overlaps here of course as although we can blame companies for employing the wrong people, the individuals themselves had a choice to make and they were in control of their own actions. Tensions will clearly lie between the employees and the companys higher figures, as much blame can and will be passed from all areas. These can be resolved by reviewing the overall outlook of the business and making sure the right people are employed for all the right ethical reasons at all levels within the corporate structure.

The final inquiry report published in 2013, condemning the actions of many involved has resulted in many resignations and the potential shutdown of the hospital which is still currently being protested against. This interesting result of people wanting a hospital that has been responsible for the deaths of many without need to be kept open because of importance of having local hospitals raises yet another ethical question. At what point is it acceptable for the standards of a person's medical needs to be lowered because of hospitals capabilities? And are we fully aware of the possible consequences such as this case?