The Francis Report and the Duty of Candour.

What happened at Mid Staffs between 2005 and 2009 was failure at all levels, affecting thousands of patients and leading to "appalling and unnecessary suffering". There was a wholesale "lack of care, compassion, humanity and leadership". The accounts of neglect in the 2000 pages of the report are deeply distressing.

The issue addressed on page 172 of Volume 1 of the Francis report stands out for different reasons. It does not involve lack of resources or dignity. It  stands out because it deals with a deliberate attempt to withhold information from a Coroner's inquest and from bereaved parents. It involves the conduct of the Trust after the death of a young patient in 2006. It is described in the report as a cause of " considerable concern and... an example of an instinctive defensiveness where openness and frankness were clearly required."

The patient died shortly after being discharged from A&E with an undiagnosed ruptured spleen. An inquest was called. The Coroner invited the Trust to submit evidence. A Consultant in A&E was invited by the former Trust solicitor to prepare a report on the case. The Consultant produced a report, addressed to the Coroner, and delivered to the Trust legal department. The Consultant concluded that a possible cause of death was a ruptured spleen. He also concluded that the death could have been avoidable if a proper assessment had been carried out in A&E.

The report was not in fact sent to the Coroner. The new Trust solicitor and company secretary then picked up the handling of this case. She wrote to the Consultant inviting him to change his report. The reasons given in her letter are described in the Francis report as "little short of astonishing". The Consultant refused to change his report and assumed it would be sent to the Coroner. In fact it was never sent.

The actual wording of the report on this issue is particularly telling. "What is particularly troubling about this unhappy story is that it was clearly thought instinctively by a senior employee of the Trust that an adverse report about care leading to a death should be suppressed, in part because of a fear of adverse publicity, and in part on a ground relating to family distress that can only be regarded as specious. "

It is difficult to comprehend a healthcare culture that reacts this way. It is difficult to understand how any individual could consider it preferable for bereaved parents not to know the truth about the death of their young son. It is tempting to believe that this was an isolated occurrence. Sadly this type of conduct is  familiar to those of us who investigate serious failings in the NHS. The tendency to suppress the results of internal enquiries and the failure to share findings with those affected is an  all too common feature of cases we see.

The Francis report calls for a Duty of Candour within the NHS.  This recommendation is welcome. Honesty and transparency must be the starting point for the new NHS. The reality is that delivering a change in behaviour without a change in culture is difficult. Most large institutions recognise that attempts at cultural change imposed from the top down may be cumbersome and ineffective.

Part of the answer to this challenge may be found in the personal experiences that resonate throughout the report. Change for the better may rely upon the power of the voice of the patient. Data about nutritional outcomes may be essential but it doesn't reflect reality for the patient who is unable to reach the meal placed nearby.  The accounts in the report are from the users of the NHS. They are the victims and witnesses of institutional and human failure. Their experiences tell us more than statistics and inspections. Their voices must be welcomed, heard and acted upon.

The accounts of patients are already recorded by many independent organisations; by Patient Groups; by hospital complaint departments and by lawyers. The information is available. The challenge for the NHS will be to access and respond to those voices...and to communicate openly and honestly with them.