The Francis report provided a detailed analysis of what contributed to serious failures in care at Mid Staffordshire NHS Foundation Trust.
Led by Robert Francis QC, the landmark report identified how the regulatory and oversight system failed to detect and address the trust's problems.
It concluded that what happened was the result of a system failure, as well as a failure of the organisation and called for a fundamental change in culture across the NHS.
Published in February 2013, its findings and recommendations have shaped health and care policy and renewed the health service's focus on delivering the highest possible care for patients.
The Government's response accepted most of Robert Francis' 290 recommendations and outlined a number of measures ensure patient safety and high-quality care. The Government announced:
- regular publication of patient safety data
- a statutory duty of candour on organisations and professional duty on individuals
- greater senior involvement in complaints handling
- guidance and tools for setting staffing levels and regular publication of actual levels
- fit and proper persons test for board members and greater performance management of very senior managers
- a new offence of wilful neglect, applicable to individuals and to organisations
- a 'Clinical Bureaucracy Index' for trusts and Concordat between national bodies to reduce bureaucracy.
The Government and regulators are responding to the quality challenge raised in the report through a series of new legal measures.