18 month old Keegan Downer died in 2015, after suffering abuse from her carer Kandyce Downer
Landmark Public Inquiry Into Stafford Hospital
A public Inquiry into the worst scandal in NHS history has been published recommending 290 reforms to the way in which the NHS is run as a whole
For over two years Robert Francis QC has been talking to staff at Stafford Hospital after routine neglect was uncovered at Mid Staffordshire NHS Foundation Trust between 2005 and 2009.
He also spoke to some of the 400 to 1200 victims families whose unnecesary deaths have led to this report being carried out. Some horrific cases were revealed from patients left soiled in their beds to people being so thirsty they had to drink water from a vase of flowers.
Robert Francis QC's report has called for a "zero tolerance" approach to poor standards in the health system.
In his report, Mr Francis attacked local health authorities and the trust board - but did not blame any one individual or organisation for the "disaster" at the hospital. He says the Department of Health put cash over patient care.
He made 290 recommendations including transparency, banishing fear to raise concerns over poor standards of care, thorough checks on wards and better recruitment, training and support in nursing.
Julie Bailey's mum Bella died at the hospital in 2007 which led her to form a campaign group called 'Cure the NHS'. Julie wanted to find out how this could have happened, demanding changes to the way in which the NHS is being run.
Heart spoke to Julie about her hopes off the back of the report, as well as speaking to lead nurses at the hospital on how they feel the report will help them. MP for Stafford Jeremy Lefroy also talked to us about how the public inquiry will affect hospitals across the West Midlands and the rest of the country:
Sir David Nicholson, who was in charge of the local strategic health authority for Stafford between 2003 and 2006, and is now Chief Executive of the NHS, admitted the "whole system" failed patients at the hospital.
A new building has opened to help support families deal with loss at Birmingham Children's Hospital.
He was found guilty of 5 charges relating to children in the 1990's
He was only charged with the offence in 2001 last year
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