Stafford hospital patients died due to NHS failings, inquiry told

Many bosses have questions to answer about hospital where between 400 and 1,200 patients died as result of 'appalling' care

Stafford Hospital: in five years from 2004, between 400 and 1,200 patients died because of 'appalling' care. Photograph: Christopher Furlong/Getty Images

Patients suffered and died unnecessarily during a hospital "disaster"because NHS bosses and groups failed to step in, the chairman of the public inquiry into the scandal said today.

Robert Francis QC pledged to identify those responsible for events at Stafford hospital between 2005 and 2009, where between 400 and 1,200 patients are believed to have died as a direct result of "appalling" care.

Francis made clear at this morning's opening session that he would conduct a thorough and searching inquiry into why organisations that were meant to be supervising the quality of treatment at the hospital fell down in that task.

In March, Francis's first inquiry – and the fourth overall – painted a picture of a hospital where sub-standard care meant patients were "routinely neglected", endured "unimaginable" distress and suffering, and were left "sobbing and humiliated" by staff.

The latest inquiry – ordered by Andrew Lansley, the health secretary, soon after the coalition took office – will concentrate on the many failings of NHS procedures for guaranteeing scrutiny, accountability and safety.

In his opening remarks, Francis said: "Last year, in my first inquiry, I sat and listened to many stories of appalling care. As I did so, the questions that went constantly through my mind were: why did none of the many organisations charged with the supervision and regulation of our hospitals detect that something so serious was going on, and why was nothing done about it? That question was one which many patients and their families – and, it is fair to say, healthcare professionals as well – wanted to be answered."

The inquiry and its conclusions are likely to prove uncomfortable, and potentially damaging to organisations such as the hospital's local primary care trust (PCT), the West Midlands strategic health authority (SHA), regulators and the Department of Health (DoH), as well as ministers who were in government when serious concerns about patient care at Stafford first emerged.

"While we are not here to re-investigate what went wrong in Stafford hospital, I think it is important, as we consider the actions and inactions of various management and organisational structures in what will inevitably sometimes be dry detail, that we keep at the forefront of our minds the terrible effect of the system's failings on those it was meant to serve," said Francis.

A total of four previous inquiries had all underlined the deficiencies in patient care, he added. One, in 2009, was by the Healthcare Commission (HCC), the then NHS watchdog in England, and the other two were undertaken by senior specialists at the DoH. Instead of revisiting the ground covered in these inquiries, Francis would seek to discover why an array of NHS bodies, locally and nationally, did not do more.

"I must look at why the system of NHS management and regulation external to the trust did not detect or act on the deficiencies before the intervention of the HCC in 2008-9. There was clearly cause for concern before that action was taken."

The inquiry would examine in detail how the system responded when relatives of patients who died at the hospital began complaining in 2008 about care there to bodies such as the PCT, SHA and DoH.

Cynthia Bower, chief executive of the Care Quality Commission, the new NHS watchdog, would have to account for her actions because she was the boss of the SHA until 2008.

Alan Johnson and Andy Burnham, both former health secretaries, rejected calls by Cure the NHS, the Stafford relatives' campaign group, and the patient safety charity Action against Medical Accidents for a public inquiry. Those groups have claimed that NHS supervisory bodies took too long to act when evidence began emerging.

"At a time of change in the NHS, it is essential that the lessons to be learned from the Stafford disaster are incorporated into its governance," said Francis.

Francis has had to postpone his plan to give Lansley his final report by the end of next March because there is so much evidence: around 150 potential witnesses and an estimated 1 million pages of written material.