Presentation of Critical Appraisal on the Francis Inquiry

Report of theReport of the Mid Staffordshire NHS Mid Staffordshire NHS Foundation Trust Public Inquiry Foundation Trust Public Inquiry

- - The Francis Inquiry - The Francis Inquiry - with 290 recommendationswith 290 recommendations

Monday 25Monday 25thth March 2013 March 2013

Akira NAITO MD PhDAkira NAITO MD PhDCT2 to Dr Duncan ANDERSONCT2 to Dr Duncan ANDERSON

Critical appraisal of this paperCritical appraisal of this paper

This paper was produced within the Inquiry Act 2005 This paper was produced within the Inquiry Act 2005 procedure although conducted by Barrister R Francis only procedure although conducted by Barrister R Francis only with nominated assessors (not by a panel of authors).with nominated assessors (not by a panel of authors).

The latest version of the paper is the second inquiry into the The latest version of the paper is the second inquiry into the same case. It was done in two fold because of the regulation same case. It was done in two fold because of the regulation the Inquiry Act 2005 was in place, i.e. restriction of time the Inquiry Act 2005 was in place, i.e. restriction of time duration and of financial limit for one public inquiry. This duration and of financial limit for one public inquiry. This increased these trustworthiness.increased these trustworthiness.

The validity and reliability of the paper appear sound. The The validity and reliability of the paper appear sound. The generalisability of this paper to other English NHS settings generalisability of this paper to other English NHS settings also appears medium to high given the provided evidence.also appears medium to high given the provided evidence.

The recommendations from this inquiry has already impacted The recommendations from this inquiry has already impacted upon all the English NHS healthcare professionals/staff and upon all the English NHS healthcare professionals/staff and managers as well as all the public in England.managers as well as all the public in England.

First report and the current reportFirst report and the current report

Final report published in 2013 Final report published in 2013

- Executive summary + Volume 1, 2 & 3 - - Executive summary + Volume 1, 2 & 3 - http://www.midstaffspublicinquiry.com/reporthttp://www.midstaffspublicinquiry.com/report

First report published in 2010First report published in 2010

- Volume 1 and 2 -- Volume 1 and 2 -http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113018 PublicationsPolicyAndGuidance/DH_113018

BackgroundBackground

The Healthcare Commission (the hospital The Healthcare Commission (the hospital regulator at the time) first raised concerns regulator at the time) first raised concerns about the trust in 2007, after determining it about the trust in 2007, after determining it had unusually high death rates.had unusually high death rates.

These concerns led to a series of reports, These concerns led to a series of reports, undertaken by different bodies, which all undertaken by different bodies, which all found widespread evidence of significant found widespread evidence of significant failures in care.failures in care.

Examples of widespread evidence of Examples of widespread evidence of significant failures in care:significant failures in care:

Patients being left in soiled beddingPatients being left in soiled bedding Patients not given ready access to food and waterPatients not given ready access to food and water Chronic staff shortagesChronic staff shortages Failure in the leadership of the hospitalFailure in the leadership of the hospital A culture in which staff members who had concerns A culture in which staff members who had concerns

about failures in care were discouraged from about failures in care were discouraged from speaking outspeaking out

The result from the first inquiry (1) The result from the first inquiry (1) (published on the 24.Feb.10)(published on the 24.Feb.10)

Lack of basic care across a number of wards and Lack of basic care across a number of wards and departments;departments;

The culture was not conducive to providing (1) good care The culture was not conducive to providing (1) good care for patients or providing (2) a supportive working for patients or providing (2) a supportive working environment for staff; environment for staff; An atmosphere of fear of adverse repercussions; An atmosphere of fear of adverse repercussions; A high priority was placed on the achievement of targets; A high priority was placed on the achievement of targets; The consultant body largely dissociated itself from The consultant body largely dissociated itself from

management; management; Low morale amongst staff; Low morale amongst staff; Lack of openness and an acceptance of poor standards;Lack of openness and an acceptance of poor standards;

The result from the first inquiry (2) The result from the first inquiry (2) (published on the 24.Feb.10)(published on the 24.Feb.10)

Management thinking was dominated by financial Management thinking was dominated by financial pressures and achieving Foundation Trust status, to the pressures and achieving Foundation Trust status, to the detriment of quality of care;detriment of quality of care;

Management failure to remedy the deficiencies in staff Management failure to remedy the deficiencies in staff and governance that had existed for a long time, and governance that had existed for a long time, including an absence of effective clinical governance;including an absence of effective clinical governance;

Lack of urgency in the Board’s approach to some Lack of urgency in the Board’s approach to some problems;problems;

Statistics and reports were preferred to patient Statistics and reports were preferred to patient experience data, with a focus on systems, not outcomes;experience data, with a focus on systems, not outcomes;

Lack of internal and external transparency regarding the Lack of internal and external transparency regarding the problemsproblems

Questions from the first inquiry (1)Questions from the first inquiry (1)

Why did the primary care trust and strategic health Why did the primary care trust and strategic health authority not see what was happening and intervene authority not see what was happening and intervene earlier? earlier?

How was the trust able to gain foundation status How was the trust able to gain foundation status while clinical standards were so poor? while clinical standards were so poor?

Why did the regulatory bodies not act sooner to Why did the regulatory bodies not act sooner to investigate a trust whose mortality rates had been investigate a trust whose mortality rates had been significantly higher than the average since 2003 and significantly higher than the average since 2003 and whose record in dealing with serious complaints was whose record in dealing with serious complaints was so poor? so poor?

The public deserve answers.The public deserve answers.

Questions from the first inquiry (2)Questions from the first inquiry (2)

The previous reports are clear that the The previous reports are clear that the following existed: following existed: a culture of fear in which staff did not feel able to a culture of fear in which staff did not feel able to

report concerns; report concerns; a culture of secrecy in which the trust board shut a culture of secrecy in which the trust board shut

itself off from what was happening in its hospital itself off from what was happening in its hospital and ignored its patients; and and ignored its patients; and

a culture of bullying, which prevented people from a culture of bullying, which prevented people from doing their jobs properly. doing their jobs properly.

Yet how these conditions developed has not Yet how these conditions developed has not been satisfactorily addressed.been satisfactorily addressed.

One of the key recommendations One of the key recommendations arising from the first inquiry reportarising from the first inquiry report

A need for an independent examination of the operation of each A need for an independent examination of the operation of each commissioning, supervising and regulatory body: commissioning, supervising and regulatory body: What the commissioners, supervisory & regulatory bodies What the commissioners, supervisory & regulatory bodies

did or did not do at Stafford;did or did not do at Stafford; The methods of monitoring used, including the efficacy of The methods of monitoring used, including the efficacy of

the benchmarks used, the auditing of the information relied the benchmarks used, the auditing of the information relied on, and a greater emphasis on actual inspection rather than on, and a greater emphasis on actual inspection rather than self-reporting;self-reporting;

Whether recent changes Whether recent changes (including the ‘Memorandum of (including the ‘Memorandum of Understanding’ between Monitor and the Care Quality Commission Understanding’ between Monitor and the Care Quality Commission (CQC), Quality Accounts and the registration of trusts by CQC)(CQC), Quality Accounts and the registration of trusts by CQC) will will improve the process;improve the process;

What improvements are required to local scrutiny and What improvements are required to local scrutiny and public engagement arrangements; and the resourcing and public engagement arrangements; and the resourcing and support of foundation trust governors.support of foundation trust governors.

The Terms of Reference set for the 2The Terms of Reference set for the 2ndnd inquiry based on the 1inquiry based on the 1stst report report

To examine the operation of the commissioninTo examine the operation of the commissioning, supervisory and regulatory organisations and g, supervisory and regulatory organisations and other agencies, including the culture and systemother agencies, including the culture and systems of those organisations in relation to their monis of those organisations in relation to their monitoring role at Mid Staffordshire NHS Foundatiotoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009; n Trust between January 2005 and March 2009; and and

The Terms of Reference (cont’d)The Terms of Reference (cont’d)

To examine why problems at the Trust were not To examine why problems at the Trust were not identified sooner, and appropriate action taken. identified sooner, and appropriate action taken. This includes, but is not limited to, examining, This includes, but is not limited to, examining, the actions of the Department of Health, the the actions of the Department of Health, the local strategic health authority, the local local strategic health authority, the local primary care trusts, the Independent Regulator primary care trusts, the Independent Regulator of NHS Foundation Trusts (Monitor), the Care of NHS Foundation Trusts (Monitor), the Care Quality Commission, the Health and Safety Quality Commission, the Health and Safety Executive, local scrutiny and public Executive, local scrutiny and public engagement bodies and the local Coroner.engagement bodies and the local Coroner.

Scope of the 2Scope of the 2ndnd Inquiry Inquiry

To make recommendations to the Secretary of To make recommendations to the Secretary of State for Health based on the lessons learned frState for Health based on the lessons learned from the events at Mid Staffordshire; and om the events at Mid Staffordshire; and

To use best endeavours to issue a report to him To use best endeavours to issue a report to him by March 2011by March 2011

Executive summary (2Executive summary (2ndnd) contents) contentsLetter to the Secretary of State Letter to the Secretary of State Page Page

33

IntroductionIntroduction BackgroundBackground 7 7 Scope of the Inquiry Scope of the Inquiry 1010 The first inquiry The first inquiry 1111 Constitution of the Inquiry Constitution of the Inquiry 1919 Responsibility and criticism Responsibility and criticism 3434

Summary of findingsSummary of findings Warning signs Warning signs 4141 Analysis of evidence Analysis of evidence 4343 Lessons learned and related key recommendations Lessons learned and related key recommendations 6565

Table of recommendations Table of recommendations 8585

Outline table of contents Outline table of contents 117117

Volume 1 (2Volume 1 (2ndnd): Analysis of evidence ): Analysis of evidence and lessons learned (part 1)and lessons learned (part 1)

Letter to the Secretary of StateLetter to the Secretary of State

IntroductionIntroduction• Warning signsWarning signs• The TrustThe Trust• Complaints: process and supportComplaints: process and support• The foundation trust authorisation processThe foundation trust authorisation process• Mortality statisticsMortality statistics• Patient and public local involvement & scrutinyPatient and public local involvement & scrutiny• Commissioning and the primary care trustsCommissioning and the primary care trusts

Volume 2 (2Volume 2 (2ndnd): Analysis of evidence ): Analysis of evidence and lessons learned (part 2)and lessons learned (part 2)

8.8. Performance management & strategic health authoritiesPerformance management & strategic health authorities9.9. Regulation: the Healthcare CommissionRegulation: the Healthcare Commission10.10. Regulation: MonitorRegulation: Monitor11.11. Regulation: the Care Quality CommissionRegulation: the Care Quality Commission12.12. Professional regulationProfessional regulation13.13. Regulation: the Health and Safety ExecutiveRegulation: the Health and Safety Executive14.14. Certification and inquests relating to hospital deaths Certification and inquests relating to hospital deaths 15.15. Risk managementRisk management16.16. The Health Protection AgencyThe Health Protection Agency17.17. The National Patient Safety AgencyThe National Patient Safety Agency18.18. Medical trainingMedical training19.19. The Department of HealthThe Department of Health

Volume 3 (2Volume 3 (2ndnd): Present and future): Present and future

20.20. CultureCulture

21.21. Values and standardsValues and standards

22.22. Openness, transparency and candourOpenness, transparency and candour

23.23. NursingNursing

24.24. Leadership in healthcareLeadership in healthcare

25.25. Common culture applied: the care of the elderlyCommon culture applied: the care of the elderly

26.26. InformationInformation

27.27. Table of recommendationsTable of recommendations

““The findings of the (2The findings of the (2ndnd) inquiry can ) inquiry can fairly be described as damning.fairly be described as damning.””

A ‘perfect storm’ of systematic failures of care, A ‘perfect storm’ of systematic failures of care, including: including:

A ‘Somebody Else's Problem’ attitude among hospital staffA ‘Somebody Else's Problem’ attitude among hospital staff An institutional culture that cared more about the needs of the An institutional culture that cared more about the needs of the

hospital staff than the patientshospital staff than the patients An unacceptable willingness to tolerate poor standards of An unacceptable willingness to tolerate poor standards of

patient carepatient care A failure to accept and respond to legitimate complaintsA failure to accept and respond to legitimate complaints A failure of different teams within the hospital, as well as in the A failure of different teams within the hospital, as well as in the

wider community, to communicate and share their concernswider community, to communicate and share their concerns A failure of leadership – in particular, financial changes needed A failure of leadership – in particular, financial changes needed

to achieve Foundation Trust status were seen, by the inquiry, to to achieve Foundation Trust status were seen, by the inquiry, to take precedence over patient caretake precedence over patient care

Concise summary video by ITVConcise summary video by ITVhttp://on.aol.com/video/mid-staffs-report--nhs-scandal-right-to-the-top-517664818

A patient deathA patient deathSystematic failure of safety?Systematic failure of safety?

Failure to:Failure to: Control diabetesControl diabetes Administer prescribed drugsAdminister prescribed drugs Undertake nursing handovers properly or at allUndertake nursing handovers properly or at all Complete nursing records adequately or at alComplete nursing records adequately or at al Make adequate or proper notes of ward rounds and Make adequate or proper notes of ward rounds and

care planscare plans Give patient a diabetic menusGive patient a diabetic menus Report this matter as a SUI in a timely fashionReport this matter as a SUI in a timely fashion Report to report to the CoronerReport to report to the Coroner

Lessons learned and related key Lessons learned and related key recommendationsrecommendations

A common culture made real throughout the system: The A common culture made real throughout the system: The negative aspects of culture in the system were identified as negative aspects of culture in the system were identified as including:including: A lack of openness to criticism;A lack of openness to criticism; A lack of consideration for patients;A lack of consideration for patients; Defensiveness;Defensiveness; Looking inwards not outwards;Looking inwards not outwards; Secrecy;Secrecy; Misplaced assumptions about the judgments and actions of Misplaced assumptions about the judgments and actions of

others;others; An acceptance of poor standards;An acceptance of poor standards; A failure to put the patient first in everything that is done.A failure to put the patient first in everything that is done.

The system’s business The system’s business not the patientsnot the patients

GPsGPs Did not look for concernsDid not look for concerns

Patient and public groupsPatient and public groups Inward lookingInward looking Insufficient support or expertiseInsufficient support or expertise

Scrutiny committeesScrutiny committees Did not listenDid not listen

PCTsPCTs Not equipped to fulfill theoretical duty re inquiryNot equipped to fulfill theoretical duty re inquiry

SHAsSHAs Did not react to potential safety implicationsDid not react to potential safety implications

DHDH Insufficient attention to safety implications of reorganisation and targetsInsufficient attention to safety implications of reorganisation and targets Insuficient information to minister on concerns about the TrustInsuficient information to minister on concerns about the Trust

Regulators missing what was Regulators missing what was important for patientsimportant for patients

CQC…CQC… Unhealthy cultureUnhealthy culture

Healthcare Commission (HCC)Healthcare Commission (HCC) Standards system which missed the pointStandards system which missed the point Proved that rigorous expert inspection worksProved that rigorous expert inspection works

MonitorMonitor Focus on finance and corporate governanceFocus on finance and corporate governance No check on quality of deliveryNo check on quality of delivery

HSEHSE Left clinical care to othersLeft clinical care to others

GMC/PMETBGMC/PMETB Limited view of patient safetyLimited view of patient safety Lack of proactivityLack of proactivity

Professional and other groups not Professional and other groups not thinking enough of patientsthinking enough of patients

RCNRCN Conflict between rolesConflict between roles Ineffective supportIneffective support

RCSRCS Information raising concerns not sharedInformation raising concerns not shared

UniversityUniversity Failed to uncover the lack of professionalismFailed to uncover the lack of professionalism

DeanaryDeanary Failed to uncover the lack of professionalism and to take acFailed to uncover the lack of professionalism and to take ac

tion to protect patientstion to protect patients

To change that: To change that:

There needs to be a relentless focus on the patienThere needs to be a relentless focus on the patient’s interests and the obligation to keep patients saft’s interests and the obligation to keep patients safe and protected from substandard care. e and protected from substandard care.

This means that the patient must be first in everytThis means that the patient must be first in everything that is done: hing that is done: There must be no tolerance of substandard care; There must be no tolerance of substandard care; Frontline staff must be empowered with responsibility Frontline staff must be empowered with responsibility

and freedom to act in this way under strong and stable and freedom to act in this way under strong and stable leadership in stable organisationsleadership in stable organisations

First recommendation First recommendation from the 2from the 2ndnd Inquiry Inquiry

While the theme of the recommendations will be a While the theme of the recommendations will be a need for a greater cohesion and unity of culture need for a greater cohesion and unity of culture throughout the healthcare system, this will not be throughout the healthcare system, this will not be brought about by yet further “top down” brought about by yet further “top down” pronouncements but by engagement of every single pronouncements but by engagement of every single person serving patients in contributing to a safer, person serving patients in contributing to a safer, committed and compassionate and caring service. committed and compassionate and caring service.

Therefore, the first recommendation of the report Therefore, the first recommendation of the report relates to the potential oversight of and accountability relates to the potential oversight of and accountability for implementation of its recommendations:for implementation of its recommendations:

Re-emphasis of Re-emphasis of what is truly important:what is truly important:

Emphasis on and commitment to common values throughout tEmphasis on and commitment to common values throughout the system by all within it;he system by all within it;

Readily accessible fundamental standards and means of complReadily accessible fundamental standards and means of compliance;iance;

No tolerance of non compliance and the rigorous policing of fNo tolerance of non compliance and the rigorous policing of fundamental standards;undamental standards;

Openness, transparency and candour in all the system’s busineOpenness, transparency and candour in all the system’s business;ss;

Strong leadership in nursing and other professional values;Strong leadership in nursing and other professional values; Strong support for leadership roles;Strong support for leadership roles; A level playing field for accountability;A level playing field for accountability; Information accessible and useable by all allowing effective coInformation accessible and useable by all allowing effective co

mparison of performance by individuals, services and organisamparison of performance by individuals, services and organisation.tion.

““Value”Value”Clarity & CommitmentClarity & Commitment

Put patients firstPut patients first Staff put patients before themselvesStaff put patients before themselves Staff do everything in their power to protect patients from aStaff do everything in their power to protect patients from a

voidable harmvoidable harm Openness and honesty with patients regardless of consequeOpenness and honesty with patients regardless of conseque

nces for themselvesnces for themselves Direct patients to where assistanve can be providedDirect patients to where assistanve can be provided Apply NHS values in all their workApply NHS values in all their work

Make NHS Constitution the shared reference point foMake NHS Constitution the shared reference point for valuer value

All NHS and contractors to commit to NHS valuesAll NHS and contractors to commit to NHS values

NHS ConstitutionNHS Constitutionhttp://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Pages/Overview.aspx

Other key recommendations (1)Other key recommendations (1)

Causing harm or death to a patient due to avoidable failCausing harm or death to a patient due to avoidable failures in care should be a dealt with as a criminal offence ures in care should be a dealt with as a criminal offence (rather than a regulatory or civil matter)(rather than a regulatory or civil matter)

NHS staff, including doctors and nurses, should have a lNHS staff, including doctors and nurses, should have a legal ‘duty of candour’ – so they are obliged to be honesegal ‘duty of candour’ – so they are obliged to be honest, open and truthful in all their dealings with patients ant, open and truthful in all their dealings with patients and the publicd the public

A single regulator of both quality of care and financial A single regulator of both quality of care and financial matters should be createdmatters should be created

Other key recommendations (2)Other key recommendations (2) Non-disclosure agreements (‘gagging orders’) – where Non-disclosure agreements (‘gagging orders’) – where

NHS staff agree not to discuss certain matters – should NHS staff agree not to discuss certain matters – should be bannedbe banned

There should be a ‘fit and proper’ test for hospital There should be a ‘fit and proper’ test for hospital directors, similar to those set for football club directorsdirectors, similar to those set for football club directors

A clear line of leadership needs to be established, so it A clear line of leadership needs to be established, so it is always clear who is ultimately ‘in charge’ when it is always clear who is ultimately ‘in charge’ when it comes to a particular patientcomes to a particular patient

Uniforms and titles of healthcare support workers Uniforms and titles of healthcare support workers should be clearly distinguished from those of registered should be clearly distinguished from those of registered nursesnurses

Proposals to improve assurance Proposals to improve assurance of Management and Quality (1)of Management and Quality (1)

An offence of causing death or serious injury to a patieAn offence of causing death or serious injury to a patient through the breach of regulatory requirementsnt through the breach of regulatory requirements

A statutory duty of candour on all healthcare providersA statutory duty of candour on all healthcare providers A criminal offence for any registered healthcare professA criminal offence for any registered healthcare profess

ional or director of an organisation to fail to provide hoional or director of an organisation to fail to provide honest information or obstruct that processnest information or obstruct that process

A common code of ethics, standards and conduct for all A common code of ethics, standards and conduct for all NHS managers to form part of contractual obligationsNHS managers to form part of contractual obligations

Support for a ‘fit and proper persons’ test, which shoulSupport for a ‘fit and proper persons’ test, which should include examination of a director's fitness to be in posd include examination of a director's fitness to be in post and a requirement to comply with a common code of ct and a requirement to comply with a common code of conductonduct

Proposals to improve assurance Proposals to improve assurance of Management and Quality (2)of Management and Quality (2)

Organisations must notify the regulator of all cases of nOrganisations must notify the regulator of all cases of non-compliance that result in dismissal or termination of on-compliance that result in dismissal or termination of appointment appointment

Disqualification of anyone found to be in serious non-cDisqualification of anyone found to be in serious non-compliance with the code from holding senior postompliance with the code from holding senior post

Creation of a leadership college to provide standardised Creation of a leadership college to provide standardised training to potential managers, which could form the batraining to potential managers, which could form the basis of an accreditation schemesis of an accreditation scheme

Strengthening oversight of governance in non-foundatiStrengthening oversight of governance in non-foundation trusts to similar standards as those for foundation truon trusts to similar standards as those for foundation trusts.sts.

List of responses from various organisations tList of responses from various organisations to the Inquity on the NeLM websiteo the Inquity on the NeLM website

http://www.nelm.nhs.uk/en/NeLM-Area/News/2013---February/06/Francis-report-Repohttp://www.nelm.nhs.uk/en/NeLM-Area/News/2013---February/06/Francis-report-Report-of-the-Mid-Staffordshire-NHS-Foundation-Trust-Public-Inquiry/rt-of-the-Mid-Staffordshire-NHS-Foundation-Trust-Public-Inquiry/ Website of Francis enquiryWebsite of Francis enquiry Prime Minister's statementPrime Minister's statement CQC responseCQC response NHS Choices assessmentNHS Choices assessment King's Fund responseKing's Fund response NHS Commissioning Board responseNHS Commissioning Board response BMJ FeatureBMJ Feature PCC report: Implications for CCGs and general practiPCC report: Implications for CCGs and general practi

cece NHS ConfederationNHS Confederation

Other reference (1)Other reference (1)

NHS Choice webpageNHS Choice webpagehttp://www.nhs.uk/news/2013/02February/Pages/Mid-Staffs-inquiry-calls-care-http://www.nhs.uk/news/2013/02February/Pages/Mid-Staffs-inquiry-calls-care-failings-a-disaster.aspxfailings-a-disaster.aspx

Francis' presentation on the King's Fund (10mins)Francis' presentation on the King's Fund (10mins)http://www.kingsfund.org.uk/audio-video/robert-francis-lessons-staffordhttp://www.kingsfund.org.uk/audio-video/robert-francis-lessons-stafford

Francis slidesFrancis slideshttp://www.kingsfund.org.uk/audio-video/robert-francis-lessons-stafford-http://www.kingsfund.org.uk/audio-video/robert-francis-lessons-stafford-presentation-slidespresentation-slides

Guardian summary websiteGuardian summary websitehttp://www.guardian.co.uk/society/blog/2013/feb/06/mid-staffordshire-nhs-trust-http://www.guardian.co.uk/society/blog/2013/feb/06/mid-staffordshire-nhs-trust-inquiry-report-published-live#block-51127e16b5790c5937938a48inquiry-report-published-live#block-51127e16b5790c5937938a48

Other reference (2)Other reference (2)

NeLM list of responses to the Francis reportNeLM list of responses to the Francis reporthttp://www.nelm.nhs.uk/en/NeLM-Area/News/2013---February/06/Francis-report-http://www.nelm.nhs.uk/en/NeLM-Area/News/2013---February/06/Francis-report-Report-of-the-Mid-Staffordshire-NHS-Foundation-Trust-Public-Inquiry/Report-of-the-Mid-Staffordshire-NHS-Foundation-Trust-Public-Inquiry/

NHS ConstitutionNHS Constitutionhttp://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documenthttp://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/nhs-constitution-interactive-version-march-2012.pdfs/nhs-constitution-interactive-version-march-2012.pdf

Inquiry act 2005Inquiry act 2005http://www.legislation.gov.uk/ukpga/2005/12/crossheading/constitution-of-inquiryhttp://www.legislation.gov.uk/ukpga/2005/12/crossheading/constitution-of-inquiry

(Criticism of the Inquiry act 2005(Criticism of the Inquiry act 2005

http://publicinquiries.org/introduction/the_inquiries_act_2005) http://publicinquiries.org/introduction/the_inquiries_act_2005)

Thank you Thank you

for your attention!for your attention!