Mid-Staffs Scandal - Being There...

...How far is it one wonders, pondering today the shame and scandal of Mid-Staffs Foundation NHS Trust, from the Boardroom at Stafford Hospital to the A&E Department? Fifty feet, fifty yards? A hundred perhaps at the outside.

How long then would it have taken a Board member (a non-exec doing his or her duty) to walk from the one to the other? Two minutes, maybe five. Hardly more.

Did any Board member choose to take that small walk to save, perhaps, a thousand lives by seeing the chaos for themselves? Doesn't appear so.

Why were phone calls not made to the Chief Constable of Staffordshire demanding that a criminal investigation begin under s.44 of the Mental Capacity Act 2005 on the grounds of 'wilful neglect or ill-treatment' of people who lacked capacity to take decisions for themselves, as clearly was the case on some medical wards? (Perhaps they were, and if not then not too late to make that call now.)

How can Monitor now claim it didn't even know about the Healthcare Commission investigation when it approved Foundation status, or the Healthcare Commission not inform Monitor of their concerns?

How in any sense can the local PCT claim to have 'commissioned' this disaster if they knew nothing of what was happening?

Where was the relevant Local Authority charged with 'safeguarding' throughout its patch?

Can it really be true that the former Chief Executive of the local Strategic Health Authority is now to be the head of the new Care Quality Commission? (When did she last visit Stafford A&E or indeed any hospital ward?)

Why would the local coroner not co-operate with the Healthcare Commission investigation when asked to do so? ("We thought that information from the coroner would be useful for the investigation. We were disappointed that he declined to provide us with any information about the number or nature of inquests involving the trust." p.11 of the report.)

Why haven't Board members fled the country in shame taking with them the architects of this whole sorry mess - those in the Department of Health and their Ministers who designed the whole 'information managed' and 'target driven' monster they have created.

And where else is this happening right now in other hospitals? I would urge today all Trust (the very word makes one wince) Board members to take a few short walks about their respective hospitals. They might learn a thing or two, not to mention save some lives in the process.

Being there is what matters, not reliance on status reports, spreadsheets and data forecasts. Worked for Taiichi Ohno, and he was only making motor cars not preventing the slaughter of patients.

(It is mercifully infrequent that one's real day job intrudes into this pleasant, if imagined, place of respite from the rough and tumble of management consultancy. This time though one is so cross one must speak. There is another world - to be kept at thorough arm's length from the happy doings of my endearing if Pooterish alter ego - and if you must go in search of further unreality you may find it at http://www.hemina.co.uk/ I am hardly ever in. This place is so much nicer!)