Lessons from Stafford.

A Public Inquiry into deficiencies at an acute hospital trust revealed not only many experiences of appalling care suffered by patients. Although it had been claimed that there were no warning signs of the poor state of affairs prevalent at the trust the Inquiry found evidence that staff, whistle-blowers and external bodies had been raising concerns the impact on patients of which were ignored or insufficiently understood. Mortality data was not accepted as showing a need to review standards of care. There was found to be a negative culture focussed on doing the system's business not that of the patients. Suggestions are made as to what trust boards should do to avoid similar issues arising in the future.