:00:03. > :00:13.Stafford Hospital. Abuse and neglect led to the unnecessary
:00:13. > :00:16.
:00:16. > :00:22.It is Christmas, 2007. In a town with a dark secret. Patients were
:00:22. > :00:27.left in horrific situations and conditions. It was just patience
:00:28. > :00:32.screaming out, banging on the doors. It was absolute bedlam. I thought
:00:32. > :00:37.the only way I would get out of that place was in a wooden box.
:00:37. > :00:41.years, appalling care at an NHS hospital has gone unnoticed. But in
:00:41. > :00:44.a cafe less than a mile away, a group of strangers are about to
:00:44. > :00:50.discover the truth. There are hundreds of patients that have been
:00:50. > :00:56.suffering and dying from neglect. It was dreadful and awful. It
:00:56. > :01:06.should never have happened. This is the story of what went wrong. And
:01:06. > :01:15.
:01:15. > :01:21.The story starts in July 2001. With another NHS scandal. And an
:01:21. > :01:25.opportunity missed. Up to 35 babies died unnecessarily at Bristol Royal
:01:25. > :01:30.Infirmary. Appalling care at Bristol Royal Infirmary has led to
:01:30. > :01:34.the deaths of dozens of babies. Investigators claim the system of
:01:34. > :01:42.monitoring care in hospitals is completely inadequate. They demand
:01:42. > :01:47.urgent reform. An -- be issued this chilling warning. For good Bristol
:01:47. > :01:52.happen again? Could it be happening right now? The honest answer is
:01:52. > :02:00.that it could. If it were happening, we would only have a slight chance
:02:00. > :02:09.of knowing. Sir Ian Kennedy was right. It did happen again. And no-
:02:09. > :02:13.one saw it coming. July, 2004. It is more than three years since the
:02:13. > :02:17.Bristol inquiry. A new hospital watchdog, the Healthcare Commission,
:02:17. > :02:22.has helped restore faith in the health service. But has it really
:02:22. > :02:27.made a difference? One woman is about to find out. Mickelham Monty
:02:27. > :02:30.has just given birth to her second child. But she returns to Stafford
:02:31. > :02:40.Hospital with a bowel condition. It is a decision she will always
:02:41. > :02:46.
:02:46. > :02:55.regret. 11 it was a very busy ward. Chaotic. Not very clean. Pilots
:02:55. > :03:00.were often felt be. -- toilets. -- filthy. I had to provide a stool
:03:00. > :03:05.samples that were left in cardboard pots. Those would accumulate in the
:03:05. > :03:14.toilets. The staff were not taking them away. Not only my own, but
:03:14. > :03:19.other people's. That would lead to cross-infection. That is exactly
:03:20. > :03:29.what happened. In the conditions, Nicola pick up not one hospital
:03:29. > :03:36.superbugs, but three. She spends the next nine months in hospital.
:03:36. > :03:43.Much of it in crippling pain. Saura swarmed all over her body. Some
:03:43. > :03:48.more than a foot wide. But the hospital hardly seemed to care.
:03:48. > :03:53.They found out that I had the infection and walked into my
:03:53. > :04:03.isolation room. She walked inside the door and threw a piece of paper
:04:03. > :04:09.
:04:09. > :04:18.in my direction and told me to read that. It was horrendous. I had been
:04:19. > :04:28.in hospital a long time. I could not see my children. I was isolated,
:04:29. > :04:29.
:04:29. > :04:39.stuck in a room on my own. Only my husband came to see me. Hours every
:04:39. > :04:45.day with me. I was still incredibly lonely and frightened. What she did
:04:45. > :04:49.not know was that the hospital's problems spread far beyond her ward.
:04:49. > :04:58.Towards the end of her stay, a member of the local patients group
:04:58. > :05:04.does a local inspection. The area itself was dirty. There were
:05:04. > :05:11.hypodermic needles out of dressings on the floor. Patients were coming
:05:11. > :05:15.in and going out and doctors and medical staff touching those
:05:15. > :05:22.patients and going to another patient and touching them. No
:05:22. > :05:29.gloves, with their hands. It does not leave much to the imagination
:05:29. > :05:35.that the probability of some form of cross infection is much higher.
:05:35. > :05:39.He was so alarmed he wrote a report. He expected the patients group to
:05:39. > :05:49.call on the hospital to take urgent action. But to his dismay, they did
:05:49. > :05:56.not. There was a culture of working hand-in-hand with the hospital and
:05:56. > :06:05.not upsetting the hospital. And there was the fear of that because
:06:05. > :06:12.of the nature of the report, that it would cause friction between the
:06:12. > :06:21.hospital and the PPI. They felt that the report should be, for want
:06:21. > :06:24.of a better word, watered down. protest, he left the group. He went
:06:24. > :06:30.directly to the hospital's new chief executive. Martin Yates had
:06:30. > :06:33.just inherited a poor management structure, a shortage of nurses and
:06:33. > :06:42.a multi-million pound debt. He told Terry that his report had prompted
:06:42. > :06:47.improvements. But he was not satisfied. He complained again.
:06:47. > :06:55.views are exaggerated. Has spent about seven or eight minutes with
:06:55. > :07:04.him at the outside. It was not very long. Someone else was also trying
:07:04. > :07:11.to raise the alarm. Someone on the inside. A nurse. I had seen people
:07:11. > :07:18.die in in a very undignified situations that could have been
:07:18. > :07:24.avoided. They were relatively frequent. On a daily basis, the
:07:24. > :07:28.poorer care and standards should never have been allowed. She blamed
:07:28. > :07:33.chronic under staffing and poor equipment. She asked managers to
:07:33. > :07:39.take urgent action. Instead, they told her simply to fill out an
:07:39. > :07:45.incident report. During her six years she would submit nearly 100
:07:45. > :07:53.forms. Not once was she given any indication they were even read.
:07:53. > :08:02.Things did not get listened to war -- or acted upon. It went right to
:08:02. > :08:08.the top. People were just not listening. That is why things got
:08:08. > :08:12.so extreme. The Department of Health then hands all hospitals two
:08:12. > :08:20.daunting new challenges. In Stafford, chief executive Martin
:08:20. > :08:25.Yates is just two months into the job. But he was told to balance the
:08:25. > :08:31.hospital's books and win Foundation Trust status. As a Foundation Trust,
:08:31. > :08:38.Stafford would have more control over its affairs. But again, the
:08:38. > :08:43.condition is a healthy bank balance. And Stafford now owes �10 million.
:08:43. > :08:48.The instruction was quite clear. Of money needed to be saved. The trust
:08:49. > :08:53.had to do that in any way it could. Ultimately, that led to them making
:08:53. > :09:01.some dangerous decisions in the years that followed. The meeting
:09:01. > :09:05.sets in motion 18 months of savage cuts. Chief executive Martin Yates
:09:05. > :09:11.makes 150 staff redundant. Next year we have got an issue to deal
:09:11. > :09:17.with. We are taking those tough decisions now so we can continue
:09:18. > :09:22.that long-term financial sustainability. But it was far from
:09:22. > :09:28.excellent. This tough decisions had an unintended impact on patient
:09:28. > :09:35.care. Staff became obsessed with noticed
:09:35. > :09:43.noticed when she was given a new bestrode up, the nurses said, you
:09:43. > :09:50.do realise this little bag costs? About �700. As if you are not
:09:50. > :09:56.were were also feeling the pinch. A lack
:09:56. > :10:00.of staff, lack of equipment. The reason always given is that we are
:10:00. > :10:05.going for a foundation status. Once we get that status, that would get
:10:05. > :10:10.better. That is a lot of why people did not speak out. And we thought
:10:10. > :10:14.that given time things would improve. The pressure was coming
:10:14. > :10:19.right from the top. The government was telling all hospitals to not
:10:19. > :10:23.only break even, but also to go for a foundation trust status. But
:10:23. > :10:30.Labour politicians denied they are partly to blame for what happened
:10:30. > :10:33.at Stafford. In a sense, that suggests that the chief executive
:10:33. > :10:41.was right to cut staff and put receptionists on trio's nursing
:10:41. > :10:49.pressure. I do not accept that at all. That was a disgracefully bad
:10:49. > :10:57.management. A year on, and Stafford's dark secret remains
:10:57. > :11:01.hidden. George Dalziel goes into hospital for an operation. His wife
:11:01. > :11:09.goes with him. What they do not know is that the hospital now has
:11:09. > :11:17.one of the highest death rates in England. Nobody was warned. It was
:11:17. > :11:24.at hing at that time. If it had been my way,
:11:24. > :11:28.he would not have gone in there. -- if I had been aware. He is
:11:28. > :11:33.operation is a success. But the couple's joy is short-lived. His
:11:33. > :11:38.epidural becomes dislodged, leaving him without pain relief for days.
:11:38. > :11:42.He is given the wrong food. That makes him throw up faeces. He is
:11:43. > :11:50.left unsold bedclothes for hours. He is too scared to ask his nose
:11:50. > :11:57.for water. He was frightened to drink. He was frightened he would
:11:57. > :12:02.wet the bed again. She was so nasty with him. He had to call her. They
:12:02. > :12:09.were left on their own all the time. If they ring the bells, it was rare
:12:09. > :12:15.if the nurses or any body came to see them. George was a brave man.
:12:15. > :12:25.He was always to reclaim. To be put in a position that he was put in,
:12:25. > :12:26.
:12:26. > :12:30.he felt ashamed and disgusted. He was so upset. When Christine visits
:12:30. > :12:40.her husband, she is so horrified by his condition that she demands to
:12:40. > :12:42.
:12:42. > :12:52.see a doctor. I helped to get his jacket of so she could examine him.
:12:52. > :12:58.
:12:58. > :13:05.Sorry. When I did it, his bones were just sticking out. I said,
:13:05. > :13:11.what on earth are you doing to him? He should not be like this. During
:13:11. > :13:21.his two weeks in hospital, George Dalziel had lost 3.5 stone. His
:13:21. > :13:30.
:13:30. > :13:39.strength had gone. When we were leaving, I said, I love you. And he
:13:39. > :13:43.says, I love you too. And that was the last words we said. That night,
:13:43. > :13:50.George Dalziel was added to the growing list of people who went
:13:50. > :13:54.into Stafford Hospital, but never came out. But what Christine did
:13:54. > :14:00.not know was that the list was being monitored by a group of
:14:00. > :14:05.statisticians. 140 miles away in London. The reason we started doing
:14:05. > :14:09.this is because after the Bristol inquiry, I realised that there were
:14:09. > :14:14.problems that could be detected by analysing the data. I wanted to
:14:14. > :14:17.make sure that Bristol did not happen again. We would send a
:14:17. > :14:27.letter to hospitals around the country and say this was an early
:14:27. > :14:41.
:14:41. > :14:48.warning. And in 2007, one hospital Each month, I am my colleague sent
:14:48. > :14:53.a letter to the chief executive Martin Yates and said we noticed
:14:53. > :15:02.you have a high death-rate for this particular diagnosis. It is
:15:02. > :15:06.possible it could be codeine or quality of care. Would you like to
:15:06. > :15:10.look and see if there are any problems. But managers and their
:15:10. > :15:15.NHS bosses will weary. They already suspected there were serious flaws
:15:15. > :15:19.in the way the hospital clerk to the data and so they commissioned a
:15:19. > :15:22.team of academics to investigate whether there could be another
:15:22. > :15:27.investigation. Their reaction was to employ somebody else effectively
:15:27. > :15:31.to try to discredit us and that was very frustrating and frustrating
:15:31. > :15:37.that they would not allow us to explain what the problem us. There
:15:37. > :15:42.were many people dying over that period. And they are the dying in
:15:42. > :15:47.their hundreds. Then in September came a day when
:15:47. > :15:53.the people of Stafford began to fight back. 86 he ruled Bella
:15:53. > :15:57.Bailey is admitted to hospital with a hernia. With her is an expert,
:15:57. > :16:07.someone who would ultimately bring staff have's problems to the nation.
:16:07. > :16:08.
:16:08. > :16:14.Her daughter is a senior social worker. -- Stafford's. It was
:16:14. > :16:18.appalling. No proper food, care, she was lying in a wet bed. If it
:16:19. > :16:23.was not for us being there, we would have lost her in the first
:16:23. > :16:27.week. Julie Bailey was so concerned, she insisted on staying at her
:16:27. > :16:31.mother's bedside during the night and it was then she saw how
:16:31. > :16:35.desperate some patients had become. I was told they could not leave
:16:35. > :16:39.drinks out at night because of health and safety. So what the
:16:39. > :16:44.confused patients would do is get out of bed and the first thing they
:16:44. > :16:51.found would be a flower vase and they would just drink out of that.
:16:51. > :16:56.It was absolutely ridiculous. November the eighth, 2007, Bella
:16:56. > :17:01.Bailey died and her daughter's campaign began. She made an
:17:01. > :17:07.official complaint but have found the response alarming. She said she
:17:07. > :17:12.had never seen anything like what I had seen and she walked towards day
:17:12. > :17:18.and night. That really shocked me and I knew. I was so desperate and
:17:18. > :17:23.I knew that if I had seen those things, other people must have. If
:17:23. > :17:28.I had lost someone that way, other people must have. I knew alone I
:17:28. > :17:33.would achieve little with that sort of response from hospital. So Julie
:17:33. > :17:36.Bailey appealed for help. In a letter to a local newspaper, she
:17:36. > :17:41.asked anyone with concerns about the hospital to get in touch and
:17:41. > :17:47.set up a meeting. The response was overwhelming. My priority was to
:17:48. > :17:54.try to stop what was going on in the hospital. When people started
:17:54. > :18:00.to write, it was a shock because I only had 16 seats. -- started to
:18:00. > :18:06.arrive. Around 25 people turned up. As they concave story, the sheer
:18:06. > :18:11.scale of the scandal becomes clear. Stafford's secret comes out. A
:18:11. > :18:18.campaign group is formed. They call themselves Cure the NHS. Inside the
:18:18. > :18:22.hospital, staff are also starting to speak out, exposing more scandal.
:18:22. > :18:28.One nurse writes a report, telling senior managers that in A&E,
:18:28. > :18:32.patient records have been routinely adopted in order to meet government
:18:32. > :18:36.targets. Weeting Heath times change so they appear to fall below the
:18:37. > :18:41.four and would limit. -- waiting times. The main culprits would
:18:41. > :18:47.routinely do this and they would encourage other staff to do it.
:18:47. > :18:52.Doctors and nurses. And if they did not want to, such as myself, they
:18:52. > :19:00.would become very aggressive and bullying basically into making
:19:00. > :19:02.people do it. The hospital investigates and Hans two nurses in
:19:02. > :19:10.prison up notices but concludes there is not enough evidence to
:19:10. > :19:15.take it further. She resigns. February 2008. The campaign to
:19:15. > :19:19.expose poor care at Stafford is gathering pace. In London, health
:19:19. > :19:23.service regulators are about to launch a full investigation,
:19:23. > :19:28.triggered by the alarmingly high death-rate. In Stafford, Julie
:19:28. > :19:34.Bailey is protesting outside the hospital. But inside, staff are
:19:34. > :19:39.putting up balloons. The reason? Stafford has just been awarded
:19:39. > :19:45.Foundation Trust status. In the eyes of the NHS, it is now a
:19:45. > :19:50.flagship hospital. You can imagine, standing outside with banners, and
:19:50. > :19:54.one of the staff, the managers from the hospital, came out and told us,
:19:54. > :20:00.we have just been awarded Foundation Trust status. I asked
:20:00. > :20:07.what it meant. They said, it's a flagship hospital. There is nothing
:20:07. > :20:12.wrong here, he said. It was like a slap in the face. Stafford Hospital
:20:12. > :20:15.faced an imminent investigation. It had one of the highest death rates
:20:15. > :20:20.in England and a public campaign against it and yet it was allowed
:20:20. > :20:28.to join the Premier League of hospitals. Giving it greater
:20:28. > :20:38.freedom to do as it pleased. One evening, just one month later, a
:20:38. > :20:40.
:20:40. > :20:44.group of experts from the Healthcare Commission conduct a
:20:44. > :20:50.surprise inspection that will alter that we expose one of the biggest
:20:51. > :20:53.scandals in the history of the health service. -- ultimately
:20:53. > :20:59.exposed. There were clearly problems but whether it was in the
:20:59. > :21:03.emergency, the medical wards or on the surgical wards, problems were
:21:04. > :21:08.there. Simple compassion and kindness, those were missing. But
:21:08. > :21:14.also, the more technical side of things. Weather observations were
:21:14. > :21:19.done properly and recorded properly. Whether equipment was used properly.
:21:19. > :21:24.Can you imagine a situation which because nurses do not understand
:21:24. > :21:29.cardiac monitors and are annoyed by their bleeding, they turn the
:21:29. > :21:34.monitors off? -- BB&T. Investigators find hundreds of
:21:34. > :21:36.patients have died from incompetence and neglect. But when
:21:36. > :21:43.they confront chief executive Martin Yates they are stunned by
:21:43. > :21:51.his response. He was actually shocked at what we were telling him
:21:51. > :21:56.and that in itself is difficult because really you should know what
:21:56. > :22:03.is going on in your own hospital. The man in charge may not have
:22:04. > :22:08.known the scale of the problem but, by March 2009, everyone did.
:22:08. > :22:14.Routinely neglected. A damning inquiry concludes Stafford Hospital
:22:14. > :22:20.lost sight of its responsibility. If for years, 25 NHS watchdogs
:22:20. > :22:25.missed what was going on. But finally, after hundreds of decks,
:22:25. > :22:30.thousands of complaints and a catalogue of reports, the man at
:22:30. > :22:38.the top was told. -- of deaths. were appalled by Stafford ANI
:22:38. > :22:43.publicly apologised on behalf of the Department of Health. It was
:22:43. > :22:47.awful and should never have happened. Should I have done
:22:47. > :22:52.something to pick up on bid earlier? Maybe. I don't know.
:22:52. > :22:57.in Stafford, the hospital's chief executive Martin Yates was
:22:57. > :23:02.suspended. He acknowledged the hospital's failings of apologised.
:23:02. > :23:12.Five years after the first complaints, something had finally
:23:12. > :23:19.changed. I struggle to find any satisfaction in knowing we were
:23:19. > :23:24.right all along. I was made to feel that I was the exception, that this
:23:24. > :23:31.sort of thing was... I was the unfortunate one person that this
:23:31. > :23:35.had happened to and it was how I responded to the situation but it
:23:35. > :23:42.wasn't. Lots of people were suffering and still continue to
:23:42. > :23:47.suffer today. This is the story of appalling and unnecessary suffering
:23:47. > :23:52.of hundreds of people. The findings of an inquiry into why
:23:52. > :23:56.the scandal was allowed to happen have now been made public. Robert
:23:56. > :24:01.Francis described a catalogue of failings at every level of the NHS.
:24:01. > :24:06.I have today made 290 recommendations, designed to change
:24:06. > :24:11.this culture and make sure that patients come first. Everything we
:24:11. > :24:17.have heard today it tells us this was systemic failings from the ward,
:24:17. > :24:22.write to the top. Just as they did after the Bristol inquiry,
:24:22. > :24:26.politicians have promised to learn from the mistakes of the past.
:24:26. > :24:30.will create a single regime where the suspension of the board can be
:24:30. > :24:34.triggered by failings in care, as well as failings in finance. We
:24:34. > :24:39.will put the boys of patients and staff at the heart of the way
:24:39. > :24:44.hospitals go about their business. -- the voice. For those who fought
:24:44. > :24:49.for change for so long, it's a defining moment. Very emotional. We
:24:49. > :24:53.will all be glad when it is over and just hope that now people of
:24:53. > :24:59.Stafford will understand what we have tried to do. Not for ourselves
:24:59. > :25:03.now, just for them. In Stafford, the hospital's future is uncertain.
:25:03. > :25:08.Riddled with debt, it survives only on government handouts. But there
:25:08. > :25:13.is a new chief executive with a new strategy. Now, when they are short
:25:13. > :25:17.of staff, it simply closes its doors. There comes a point when you
:25:17. > :25:22.have to make difficult decisions around safety. In the case of the
:25:22. > :25:27.emergency department, that is what we do. There is no point trying to
:25:27. > :25:32.run a walk safely if you have not got the right number of nurses and
:25:32. > :25:36.doctors. I think the care is very much better than it was two or
:25:36. > :25:42.three years ago. We are not perfect, we do not get it right every time,
:25:42. > :25:47.but I think the standards have dramatically improved.
:25:47. > :25:53.Perhaps, finally, Stafford has a hospital we can trust. But those
:25:53. > :25:58.who suffered their have heard it all before. They have wasted so