Phil Sugden

The Francis Report:
Patients First and Foremost
The Findings – What went wrong
• Patients and families were not listened to
• Multiple warning signs not spotted or acted
• Information not shared and inadequate
action taken
“The system failed in its most essential duty, to
protect patients.”
The Findings – Keys themes
Values and Standards
Openness, Transparency and Candour
Compassion and Care
Addressing the Themes
• The CNO’s vision and strategy for Nursing, Compassion in
• Authorisation process for CCGs with a clear focus on
quality, shaped by the first Francis report
• Commitments made in planning guidance, Everyone Counts
• Respond to the final report on Winterbourne View
• Organisation Development Strategy, as a key driver of
cultural change
• The National Quality Board and the NHS Leadership
Academy will play key roles in shaping the new culture
• Sir Bruce Keogh’s investigation into hospitals which are
outliers on measures of mortality
Patient First and Foremost
Collective Commitment
• Apologises for failures
• Commits to putting patients first and listening
• Commits to doing the business of the patient, before
that of the organisation or the system, with a direct
connection to patients and frontline staff
• Commits to working together to tackle poor care and
promote excellent care in a spirit of openness and
“Changing ourselves, our behaviour, individually and
institutionally, is difficult, but we pledge to do so.”
Patient first and Foremost:
Initial Response
Preventing Problems
Detecting Problems Quickly
• Time to Care and Space to lead
• Focus on Safety (Berwick Report)
• Chief Inspectors
• Staff and Patient voice
• Ratings
• Statutory duty of Candour
Taking action Promptly
• Fundamental Standards
• Single Failure Regime
Ensuring Robust Accountability
• HSE Powers
• Professional Regulation
• Barring Failed Managers
Ensuring Staff are Trained and
• Training
• Leadership
• Revalidation

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