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Mid Staffordshire NHS Foundation Trust

I thank the Secretary of State for early sight of his statement. This is an utterly shocking scandal, which is a stain on the good name of the NHS. It demonstrates again horrifying evidence of patient neglect, which should never feature in the national health service. I welcome the recognition in the statement that there are national lessons to be learned, but the focus of the inquiry was none the less on this particular trust. It seems to me that the inquiry was not designed to ensure that the full wider lessons could be learned. It was not designed to hold anyone to account, which it specifically says, as the terms of reference did not permit investigation into the role of any of the external agencies. It was also held in private. The inquiry was not able to consider the reports of any of the individual cases through a separate process because they were not ready in time. The report itself confirms that disappointing numbers of staff came forward to give evidence. That is not good enough. It is not the fault of the inquiry, but the fault of the process created by the Government. The bottom line is that the report will not satisfy the families of those who lost their lives and it will not bring an end to demands for a full public inquiry. I also pay tribute to the work of Julie Bailey and the organisation Cure the NHS. Do not the findings reinforce the need to learn wider lessons about the causes of the failures that took place in the hospital: the focus on process at the expense of outcomes; the failure to listen to those who receive care; staff disengaged from the process of management; insufficient attention to the maintenance of professional standards; a weak professional voice in management decisions; abuse of vulnerable elderly people; and a lack of transparency? The key point is that none of those findings can be said to be unique to this particular trust. The hon. Member for South Cambridgeshire (Mr. Lansley) highlighted other failing hospitals that the House has debated. There is surely a need for a full public inquiry, and it should surely first consider the pay-off to the chief executive and the fact that people are too often rewarded for failure. This chief executive received £400,000. I have a copy of the private investigation into his actions. Surely it should be published in full—it is heavily redacted, which amounts to a cover-up of the full findings of the investigation. It points to a case for disciplinary action, yet there was a very substantial pay-off to this chief executive. A public inquiry should also look at the role of targets. The statement rightly said that blaming targets in their entirety would let management off the hook, but not looking at targets lets the Government off the hook, given that targets played a part in the failures of this hospital. It is also essential to look fully at the role of regulation. I am pleased that there will be a further inquiry into that, but it should surely be held in public and should look at the complex web of regulation that we have created. The fact that we have five different national organisations with some responsibility for patient safety has resulted in no one taking proper responsibility for it. In Basildon, for example, there were 21 visits by seven different organisations in the year before the final report emerged. We need to look at the devastating report into the role and failure of regulation that was commissioned by the NHS Confederation last summer. It showed that we have ended up with paper safety rather than real patient safety and a tick-box culture. A public inquiry should also look at the process for securing foundation trust status, which provided a false reassurance to people that the hospital was performing to a high standard. Finally, do we not owe it to the families of those who have lost their lives to have a full examination in public of the wider lessons that need to be learned from this scandal?