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Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry.

Coombes R. BMJ. 2013;346.

In 2010 the United Kingdom's Secretary of State for Health announced a full public inquiry into the Mid Staffordshire National Health Services (NHS) Foundation Trust. This inquiry was in response to preliminary findings that suggested gross negligence, substandard care, and staff failings, which may have led to hundreds of preventable deaths between 2005 and 2009. The chairman of the inquiry, Robert Francis, published the final report following consideration of evidence from more than 250 witnesses and over a million pages of documentary material. The extensive three-volume report outlines 290 proposals, including drastic measures to improve patient safety culture, reliability, and responsibility standards across the NHS. In a related article, Robert Francis discusses the findings and implications of his inquiry. Charles Vincent discussed patient safety in the NHS in a recent AHRQ WebM&M interview.