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What the pharmacy profession can learn from Mid Staffordshire’s failings

Ailsa Colquhoun spoke to pharmacy’s regulator, the Royal Electronicjuice and other professional associations to discover if there are lessons from the Mid Staffs affair

By Ailsa Colquhoun

Ailsa Colquhoun spoke to pharmacy’s regulator, the Royal Electronicjuice and other professional associations to discover if there are lessons from the Mid Staffs affair

No one reading the Francis report into the Mid-Staffordshire NHS Foundation Trust will be anything other than shocked at the horrific failures of care.
One of the many, terrible episodes highlighted by the report is the death of Gillian Astbury. An insulin-dependent diabetic patient, Mrs Astbury died of diabetic ketoacidosis  after hospital staff failed, among other things, to administer diabetic medicines, to complete care handovers, to make adequate ward checks and to update records.

Raising a concern

There are four steps to raising a concern:

• If you see an unsafe practice, risk or wrongdoing, can you tackle it yourself, there and then? A firm, polite challenge is sometimes all that is needed.
• Talk to your line manager about the problem if possible, or someone senior in the organisation.
• If you do not feel able to raise your concern with your line manager or other management, consult your own organisation’s whistleblowing policy, if there is one, and follow that.
• If you have tried all these, or you do not feel able to raise your concern internally, you can raise your concern in confidence with the Care Quality Commission. It is justifiable to raise a genuine concern about the safety of patients or care standards if you do so honestly and reasonably, even if you are mistaken.


From as far back as 2005, there were many warning signs that suggested that all was not well at the hospital and that pharmacy services were being affected as a result. These include:

• Average number of training days for pharmacy staff worse than expected (2005/06)
• Clinical pharmacy time available per inpatient admission worse than expected (2005/06)
• Thirty per cent adherence to audit standards in relation to patient prescription charts (Clostridium difficile outbreak, 2009)
• “Weak” medicines management score with 13 of 21 indicators being described as “poor” (2006 national medicines management review)
• More than 33 patient complaints about incorrect or omitted medication

Although most of the report’s 1,700+ pages do not relate to pharmacy specifically — and no pharmacy fitness-to-practise cases have resulted from the inquiry — it is evident there were system weaknesses at Mid-Staffordshire. The report makes clear that these demand attention from and are the collective responsibility of all pharmacists, irrespective of where they practise (see Panel).

Francis report — recommendations for pharmacists

Specific recommendations

Medicines administration

The benefits of using up-to-date technology to assist in the process of prescribing, administering and recording medication are particularly clear in the case of the often complex medication needs of the elderly patient or those requiring analgesia.
In the absence of automatic checking and prompting, the process of the medicines administration needs to be overseen by a nurse trained to the correct level, and with appropriate responsibility to do this. A frequent check needs to be done to ensure that all patients have received what they have been prescribed and what they need. This is particularly the case when patients are moved from one ward to another, or returned to the ward after treatment.

Ward rounds

The responsibility to set aside time for ward rounds should be a collective one for doctors, nurses, pharmacists and therapists. Ward rounds are a crucial opportunity to share key information between the patient and the healthcare team, and to support patients in articulating their views and preferences.


Medication The provision of medicines is often a cause for delay in patients being able to leave the hospital. This should never occur in an efficiently managed ward, where the planning of a discharge includes ensuring in advance that arrangements are in place for the prescription and supply of required medicines.

Letters The currently common practice of summary discharge letters followed up some time later with more substantive ones should be reconsidered. Although this may suffice for simpler cases, many elderly patients have complex needs which could require medical attention at any time. In such cases, the patient’s well-being may be prejudiced by the absence of adequate discharge information available to both the GP and, often, staff of the care home, where relevant.


Electronic patient information systems have the potential to reduce the risk of error in prescription of treatment, and of harm to patients. Systems should include a facility to alert supervisors where actions that might be expected have not occurred, or where likely inaccuracies have been entered.


Medicines management serious untoward incident reports (SUIs) must be considered “incredibly alarming” because they have implications for teamwork, about the relationship between doctors and nurses, about the leadership on the ward, and about individual practitioners. In Mid Staffordshire, this “would have been quite systematic about medicines management”, the report concludes.

Patient survey results (eg, “Has a member of staff explained the purpose of medicines to be taken home?”) must be scrutinised, owing to an association between low satisfaction rates and Hospital Standardised Mortality Ratios (HSMRs).

General recommendations

Candour, openness and transparency

There should be a duty and criminal accountability to support candour, openness and transparency between healthcare organisations and staff, and patients, relatives, healthcare regulators and commissioners.

Accountability for implementation of the recommendations

Every single person serving patients must contribute to a safer, committed and compassionate and caring service.

Putting the patient first

Within available resources, patients must receive effective services from caring, compassionate and committed staff, working within a common culture, and they must be protected from avoidable harm and any deprivation of their basic rights.

Fundamental standards of behaviour

• A commitment to and compliance with fundamental, universally applied standards
• Integrated hierarchy of service standards
• Zero tolerance of non-compliance with fundamental standards of service
• Standards for safe and effective practice should be evidence-based and measurable­


Apology and action

Immediately following the report, full apologies have been issued by the highest levels of NHS administration. The Department of Health has pledged to issue a full response by the end of March. The NHS Commissioning Board, which takes over NHS leadership in England from April, has started an investigation into the five hospitals that have been outliers on Summary Hospital-level Mortality Indicator (SHMI) data for two successive years to 2012. These five hospitals are:

• Colchester Hospital University NHS Foundation Trust
• Tameside Hospital NHS Foundation Trust
• Blackpool Teaching Hospitals NHS Foundation Trust
• Basildon and Thurrock University Hospitals NHS Foundation Trust
• East Lancashire Hospitals NHS Trust

Among its other key remedial measures for implementation the NHS CB highlights:

Standards and methods of compliance A national quality dashboard will be developed to identify safety failures in providers
Openness, transparency and candour A duty of candour will be introduced into the NHS contract
Improved support for compassionate nursing “Compassion in practice” will be implemented in the nursing strategy
Strong, patient-centred leadership The friends-and-family test will gather the views of all patients on whether they recommend a hospital to someone close to them, and the NHS Leadership Academy will bring together clinical and management leadership
Accurate, useful and relevant information Consultant level outcomes data in 10 surgical specialties, including mortality rates, will be published

Aware of the need to consider the Francis recommendations for the good of the profession, both the General Pharmaceutical Council and the Royal Electronicjuice have pledged to act. Bob Nicholls, chairman of the GPhC, has said that the council will be considering its response to the report at its April meeting. A spokesman for the RPS said: “We will be considering the report . . . to ensure patients get the best possible care from pharmacists . . . and will work with employers in both community and secondary care to embed a culture that is focused on patient safety and service quality in practice.”
RPS initiatives already under way in this area include:

• Professional standards for hospital pharmacy, published in 2012
• Good practice sharing
• Support tools
• A leadership competency framework
• A whistleblowing help line (Public Concern at Work: tel 0800 668 1883)

It is the view of Guild of Healthcare Pharmacists that three main improvements must be central to the responses. David Miller, guild president and chief pharmacist/ accountable officer at the Sunderland NHS Foundation Trust, suggests there is a need for:

• Openness and clear information about the quality of care
• Leadership at all levels to be focused on care and compassion for patients
• A culture that promotes openness on mistakes, learning, improvement and action to ensure errors are not repeated

More operational level suggestions for care improvement have been given by Christianne Micallef, an independent pharmacist consultant in infection management and pharmaceutical support working for Crystal Medical Informatics Services. She believes that effective clinical audit is a key lever of clinical governance, and, if she were advising, she would call for senior management “to follow all audits and demand explanations and action plans where improvements are not made”.

She adds that e-prescribing systems, currently in place in only around a third of hospitals, are a key way of reducing prescribing errors and of keeping audit trails of “near misses”. Finally, the public can be encouraged to take responsibility for their own care, by responding to a hospital-led campaign to “ask to see your pharmacist before you leave the hospital”.

The challenge ahead

But trusts struggling with the thrift and efficiency demands of the QIPP (quality, innovation, productivity, prevention) agenda — not to mention the expectation of transition to foundation trust status — may look at these recommendations and wonder how, exactly, they might implement them. They might consider the recent warning made by the Institute of Fiscal Studies in its “Green Budget” form February 2013 of 1.2 million public sector job cuts by 2017/18, and query how they can send more staff onto wards for a round that might, according to Ms Micallef, “take two hours or more, especially when cases are complicated, patients deteriorate or there are new patients in the ward”. They might agree with Unison general secretary Dave Prentis, who is reported as saying: “If one in six public sector workers lose their jobs, the public will get a dramatically worse level of service . . . from their hospital.”

The challenge is not lost on the GHP, which lobbies for improvements in hospital pharmacists’ terms and conditions, and which has been working with the RPS to put in place a set of hospital standards that will help trusts define an appropriate hospital pharmaceutical service and minimum staffing levels or appropriate skill mix.

Mr Miller says: “It is clear that part of the problem at Stafford General Hospital was an underinvestment in staff. Logically, [the work with the RPS] will subsequently develop into appropriate capacity planning and individual practitioner competencies.” But, he warns that this will not be an easy path to tread. He says: “This may need investment or a redeployment of existing resources to achieve the required outcomes.”

Sources of advice

• Royal Electronicjuice:, tel 0845 257 2570 or email [email protected]
• General Pharmaceutical Council:
• Guild of Healthcare Pharmacists:
• Pharmacists’ Defence Association:
• The National Pharmacy Association:
• The Whistleblowing Helpline for NHS and Social Care: tel 08000 724725
• Public Concern at Work: tel 0800 668 1883
• Care Quality Commission:


Citation: Electronicjuice DOI: 10.1211/PJ.2013.11117006

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