Action points ignored after damning report

Experts behind a damning probe into Stafford Hospital's surgery department failed to check if bosses at the trust acted on their findings.

The Royal College of Surgeons wrote a highly critical report about surgeons at the hospital after an investigation in 2007, but it never checked if the trust took any action.

Two years later, another probe found the surgery department was "unsafe and at times frankly dangerous". A review of 40 patients identified serious poor care and unnecessary deaths.

The public inquiry into what went wrong at the Mid Staffordshire Trust heard evidence yesterday from John Black, president of the RCS who told the hearing he wished the college had checked up on the hospital.

The RCS was invited into the trust in 2007 because of concerns about a surgeon and the general running of the department.

The report raised major concerns for patient safety. One recommendation was that psychologists be brought in to treat the surgeons.

Mr Black said the RCS made recommendations which it was the duty of the hospital to follow.

Counsel to the inquiry Tom Kark QC asked Mr Black what the RCS did after the report was handed to the hospital. He replied: "We wrote to them but we never made sure that the recommendations had been carried out."

Mr Kark said: "Do you recognise that for a member of the public listening to that, to say it is unacceptable is putting it mildly?"

Mr Black answered: "I would accept that. The recommendations were made to the trust and we didn't follow it up, and I wish we had done."

The RCS has no powers to force hospitals to act on its findings.

Mr Black described the findings of the 2009 report, as an "appalling" situation.

He said surgeons had a duty to raise concerns about poor care in hospitals, but the RCS did not pass its findings to the Healthcare Commission in 2007 or the Care Quality Commission in 2009.