By Chris King, special correspondent
Our timeline on this page takes a look at the main evidence from the public inquiry into the failings at Stafford Hospital. The inquiry started in November 2010.
The inquiry is looking into the failings of the regulatory bodies and organisations which should have been monitoring the hospital's performance.
On this page you can see a diary of some of the more important pieces of evidence delivered at the inquiry. BBC reporter Chris King is the BBC's special reporter at the inquiry.
Back in November 2007, Stafford resident Julie Bailey set up the Cure The NHS campaign group after her mother Bella died in Stafford Hospital. She had been horrified by the treatment her mother received, and found out she was not the only one with concerns.
It took three years of campaigning by CTN, but finally, a full public inquiry got underway in November 2010.
An earlier investigation by the NHS watchdog, the Healthcare Commission, had already concluded that hundreds more people died at Stafford Hospital between 2005 and 2008 than should be expected. It said the hospital's "appalling" emergency care resulted in patients dying needlessly.
28 September: Sir David Nicholson, Chief Executive of the NHS (Day 2)
Sir David told the inquiry that in 2006 the NHS was more focused on finances than quality of care, and that sometimes there was an over-reliance on formal pieces of paper. He went on to say that the problems at Stafford Hospital have had a profound effect on the entire health service, and that hardly a day went by when they didn't talk about it. He also told the inquiry that a unit had been set up to implement the lessons of the public inquiry, and that steps had already been taken to improve the handover process during the transfer of powers from Primary Care Trusts to GP commissioning boards.
He was asked about claims by the trust's former chief executive, Martin Yeates, who claimed he had not been allowed more time to sort out the trust's finances. Sir David told the inquiry that the Strategic Health Authority had offered him a loan of £1m to ease the burden, but it had been turned down.
27 September: Sir David Nicholson, Former Interim Chief Executive of NHS West Midlands, currently Chief Executive of the NHS (Day 1)
From 2005-2006, Sir David oversaw the merger of three Strategic Health Authorities in the West Midlands into one. At the time there was a national drive to save money across the NHS, but Sir David told the inquiry that, because the trust only had a small deficit, it wasn't seen as a concern. He was also on the interviewing panel which appointed Martin Yeates as the permanent chief executive of the Mid Staffordshire Trust in 2006, saying he had a considerable amount of operational experience. Sir David admitted to the inquiry that knowing what they knew now, he was the wrong man for the job. He was also on an SHA panel which scrutinised the trust's plans to gain Foundation Status but said they didn't discuss proposals to cut nursing staff because it wasn't brought up by their advisors.
In 2008 when the Healthcare Commission launched its investigation into high death rates at the trust, Sir David said he spoke to Martin Yeates who was said to be upset about the investigation and the way it was being carried out. He says he would have told Mr Yeates to cooperate with inspectors, and be honest with them about any problems. Ultimately though "he's a Chief Executive, you just have to deal with it".
26 September: Sir Hugh Taylor, Former Permanent Secretary of the Department of Health
Sir Hugh used his statement to say that in his opinion it was a failure by local health managers, but ultimately the Department of Health has to take some responsibility for what has happened. He said that they had learnt some lessons from the failings at the Mid Staffordshire Trust, saying that everyone should have worked more closely together to support it. He also denied that once the Healthcare Commission released its report into the trust that they had tried to challenge the findings. Their priority was "how could this happen, and is the hospital safe now.
22 September: Una O'Brien Permanent Secretary to the Department of Health & Former Director General of Policy and Strategy
Una O'Brien is the most senior civil servant within the Department of Health. In her previous role she also played a part in the establishment of the Care Quality Commission. She expressed sympathy for those who had lost relatives, and apologised that the department had missed their concerns. Ms O'Brien admitted the system they used for processing letters wasn't suitable for handling complaints, which is why members of Cure the NHS received replies telling them to contact the hospital. She says the system has now been improved. She ended by saying that they wanted to learn the lesson which would come out of this report.
21 September: Announcement by the Chairman Robert Francis QC
The inquiry counsel announced that the inquiry would hear from the former chairman of the Mid Staffordshire Trust on 3 October, and on the same day the statement of former chief executive Martin Yeates would be read out. The inquiry chairman, Robert Francis, explained that both had been assessed by an independent medical advisor, as a result Mr Yeates would not be giving evidence, and Mrs Brisby would be appearing via a video link. Cure the NHS were also successful in their application to call the former head of Governance at the Trust, Trudi Williams, to give evidence.
21 September: Gary Belfield - former Acting Director General of Commissioning
Gary Belfield held the position from July 2009 - May 2010. One of his main roles was to develop and oversee the system used by Primary Care Trusts to commission services from local care providers. He told the inquiry that most PCTs would have relied on hospital managers to tell them if they were meeting the minimum standards expected of them. Mr Bellfield also expressed his surprise that South Staffordshire PCT didn't pick up on more of the warning signs. But he also believes that the new GP-led commissioning boards would be in a better position to pick up on any future problems within a hospital.
20 September: Professor Sir Bruce Keogh - Medical Director of the NHS in England
Sir Bruce told the inquiry that he was aware of the Healthcare Commission investigation into the Mid Staffordshire Trust, but wasn't shown a letter sent in May 2008 which raised serious concerns about the Accident and Emergency department. He told the inquiry the letter probably went to another part of the department who would have assumed that NHS West Midlands or South Staffordshire Primary Care Trust was dealing with it. Sir Bruce was however shown the draft HCC report which included examples of poor standards of care, but he told the inquiry he didn't intervene because the HCC said there was no need to do so. He also said that this wasn't just a managerial failure but that doctors and nurses had to take responsibility for what had happened too, and that they had let down patients in their hour of need.
15 September: David Flory, Deputy Chief Executive of the NHS & Director General of Finance, Performance and Operations
David Flory keeps an eye on the financial situation across the NHS in England, as well as holding NHS organisations to account. The inquiry heard that he had been told about the Healthcare Commission's investigation into the Mid Staffordshire Trust but decided not to interfere. He was asked why the Department of Health took no action after receiving a copy of a letter from the HCC which raised serious concerns about Stafford's A&E department. Mr Flory replied that because it was a Foundation Trust it was not the job of the department, nor any other organisation to performance manage it, before adding that the HCC could have asked for it to be put into special measures but didn't. The letter was eventually passed on to NHS West Midlands.
14 September: John Holden, Director of System Regulation at Department of Health and former head of Foundation Trust team (March 08 - Aug 09)
John Holden oversaw the Foundation Trust application process whilst the Mid Staffordshire Trust was being investigated by the Healthcare Commission. He told the inquiry that the release of the HCC report in March 2009 tested the limits of Monitor's relationship with the Department of Health. The inquiry saw an email which suggested that the NHS Business Unit wanted to "drop Monitor in it" although Mr Holden claimed he couldn't remember what he actually meant. He said at the time all the organisations involved would have to explain their actions. The inquiry also heard that since the HCC Report was released the Foundation Status application process has been tightened, and the Department of Health requires more information before allowing a trust to apply.
13 September: Sir Andrew Cash, former Director General of Provider Development at the Department of Health
Sir Andrew Cash chaired the "Star Chamber" - a committee of civil servants which decides whether an NHS Trust should be allowed to apply for Foundation Status. The inquiry heard that they relied on local Strategic Health Authorities to highlight any problems, but didn't require the SHA to send them all the information which they had gathered. Sir Andrew also claimed that the committee was unaware of concerns about high death rates at the trust which had previously been published in The Telegraph. He did however say that if they had more information they probably wouldn't have sent it through to the next stage, but at the time he believed it was the correct decision.
12 September: Warren Brown, former Head of Foundation Trust team (March 2006-March 2008)
Warren Brown was in charge of the Foundation Trust application process during the time that the Mid Staffordshire Trust was being considered. The inquiry heard that in 2007, Downing Street was concerned about the low number of trusts applying. The criteria was changed so that organisations which had gained two stars in the annual ratings system could apply (it had previously been only 3 star trusts). Mr Brown denied that this was lowering the bar, just widening it, as the entry criteria hadn't changed. He was also on the committee which recommended to the Health Minister Andy Burnham that Mid Staffordshire be allowed to apply for Foundation Status. He told the inquiry that they relied on information provided by NHS West Midlands and that nobody was charged with looking at clinical quality. He said that when Mr Burnham approved the application he did have enough information, and would have understood that it was "just good enough" to get through.
8 September: Dame Christine Beasley, Chief Nursing Officer for England
Dame Christine Beasley acts as an advisor on policy for the Department of Health, and also oversees the training of managers, but doesn't directly manage any nurses. The public inquiry heard that she wasn't aware that the Healthcare Commission was investigating the Mid Staffordshire Trust, although she wouldn't have expected to have been told.
Dame Christine also said she hadn't seen a letter sent by the HCC in May 2008 which raised serious concerns about A&E, including a shortage of nurses, but felt she probably should have been told about it. She also said that the former Director of Nursing, Helen Moss, should have acted more quickly in identifying, and resolving the problems with staffing levels at the trust.
7 September: Ben Bradshaw MP, former Health Minister (June 2007 - June 2009)
Mr Ben Bradshaw was responsible for regulators during his time at the Department of Health. He told the public inquiry that he was aware that the Healthcare Commission was investigating the Mid Staffordshire Trust but didn't intervene because he wanted to allow investigators to get on with the job. The inquiry heard that he didn't know about the lack of communication between the HCC and Monitor which meant the latter wasn't made aware of concerns about death rates at the trust. Mr Bradshaw also said he was shocked by the lack of complaints from local people.
6 September: Andy Burnham MP, former Health Secretary and Health Minister
In July 2007, Andy Burnham allowed the Mid Staffordshire Trust to apply for Foundation Status. The inquiry heard that he was following official advice and had not been told about previous concerns by civil servants who at one point had considered the application "difficult to support". The advice he was given totalled four lines and raised concerns about the business plan but said the management had a "can do" attitude so any issues could be overcome.
He became Health Secretary in June 2009, which was three months after the Healthcare Commission report was released. He told the inquiry that he was shocked that there was still no permanent Chairman or Chief Executive at the trust and told the Chief Executive of the NHS to find one. He also says officials at the Department of Health urged him not to hold an inquiry into what happened because the cost would outweigh the benefits.
5 September: Hilary Jones - Dean of the Faculty of Health at Staffordshire University
Stafford Hospital provides training placements for around four hundred students at Staffordshire University every year. Hilary Jones said that it was "neither the best nor the worst" trust they dealt with although the relationship wasn't as easy or as comfortable as with other trusts. The inquiry was also shown eight complaints made by students six of which related to either bullying and aggressive treatment or patient care. Miss Jones said the number of complaints was not dissimilar to those received about other trusts.
5 September: Dr Elizabeth Hughes - Postgraduate Dean for the West Midlands Deanery
Dr Hughes oversees the training of doctors for the entire West Midlands and is part of the Strategic Health Authority. She took up the post in 2007 there had been no active scheme to assess the quality of training placements, and that people within the Deanery were unsure as to whether they should be carrying out inspections.
The inquiry heard that no concerns had been raised about the hospital until June 2008 when a doctor complained about staffing levels in Accident and Emergency. She was also unaware of the Healthcare Commission Investigation into the trust, and a letter from the HCC raising serious concerns about A&E. That was despite the fact her line manager had been copied in on it.
Note: Public inquiry takes a summer break from 7 July - 5 September
16 June: Dr Musarrat Afza, Consultant in Communicable Disease Control, Health Protection Agency (HPA)
Dr Afza first came into contact with the Mid Staffordshire Trust in July 2008 during an outbreak of C-difficile, and she attended regular infection control meetings with management. At the time she identified several areas which needed to be addressed which included the lack of specific wards to isolate patients with infectious diseases, problems with the prescribing antibiotics and the need for access to cleaning equipment 24 hours a day. There were two further outbreaks: one in September 2008 and another in January 2009. The inquiry heard that at that time, there were still no isolation wards, no antibiotic pharmacist, and when they checked, the commodes they were all dirty.
16 June: Justin McCracken, Chief Executive, Health Protection Agency (HPA)
The inquiry heard that the HPA advises NHS managers on how to prevent the spread of infectious diseases, but cannot force them to make them implement changes. Justin McCracken said that in March 2009, the trust was reluctant to declare that it had an outbreak - putting patients at risk of infection. He also said that they struggled to get information from the trust about infection rates. Mr McCracken told the inquiry they made several recommendations which weren't followed and that it felt like they were "banging our heads against a brick".
9 June: Mike Brereton, former Chairman of the Shropshire and Staffordshire Strategic Health Authority (SSASHA)
Mr Brereton told the inquiry that the Mid Staffordshire Trust faced "challenges" but it didn't stand out, although there was a feeling that the management needed "refreshing". The general consensus was that it didn't embrace change, and so in 2005, Toni Brisby was brought in as the Chairman, and the Chief Executive, David O'Neill, was persuaded to move to another trust. He was replaced by Martin Yeates, and the relationship was described as one of "support and encouragement" because it was a new team. Their target was to gain foundation status but Toni Brisby was warned that her timescale for doing so may have been a little ambitious. He also admitted that at the time much of the focus was on the University Hospital of North Staffordshire which had just seen its entire board resign.
2 June: William Price, former Chief Executive, South Western Primary Care Trust*
William Price was asked about a report published in 2001 which raised concerns about the management at Stafford Hospital. It highlighted problems with short staffing, the inability of some agency nurses to operate equipment, and a lack of communication with outside organisations. Mr Price told the inquiry that it was also difficult to get certain information from them, and that when they did receive it, it wasn't of particularly good quality. He said that despite his concerns, he had no power to remove the chief executive David O'Neill, who stayed on for another four years.
*The South Western Primary Care Trust was formed in 2001 and disbanded five years later when it was merged into the South Staffordshire PCT.
1 June: Dr William Moyes, former Executive Chairman of Monitor (Day 2)
The focus of today's evidence was on Monitor's reaction to the launch of the investigation by the Healthcare Commission. Dr Moyes told the inquiry that they didn't want to take action against the trust until the HCC had reached a conclusion and made specific recommendations. In April 2008, the trust's chairman Toni Brisby admitted that there were issues which had not been mentioned during the application process, but he had decided to give her "the benefit of the doubt". He did however say that the board was told to fully cooperate with investigators. In the weeks up to the report being released, Dr Moyes said that he'd tried to persuade the former chief executive Martin Yeates to stay on for three months so as not to deter the appointment of the new medical director, Manjit Oberei. Mr Yeates was also in talks with the Strategic Health Authority over the possibility of a new job. In the end he stepped down at the same time as Toni Brisby.
31 May: Dr William Moyes, former Executive Chairman of Monitor (Day 1)
Dr Moyes told the inquiry that, with the benefit of hindsight, they shouldn't have granted the Mid Staffordshire Trust Foundation Status, and that the Department of Health shouldn't have put it forward for consideration. He also admitted that the board was not straight with Monitor and hadn't mentioned problems at the hospital during the application process.
31 May: Stephen Hay, Chief Operating Officer, Monitor
Mr Hay said that in 2007 they didn't have a "systematic and robust framework to test clinical governance", and they relied heavily on the annual ratings given to Foundation Trust applicants by the Healthcare Commission. At that time, trusts needed to have a three star rating but there had been a suggestion that there should be no entry criteria at all. In the end it was lowered, but Mr Hay said they didn't think about how that would affect their assessment process. It also emerged that there was confusion from the HCC about when they should contact Monitor with concerns, and despite drawing up a "memorandum of understanding", there was no way of routinely checking the quality of care offered at a trust.
26 May: Edward Lavelle, former Director of Regulatory Operations at Monitor
Edward Lavelle was in charge of regulating NHS trusts after they have been awarded foundation status. The focus of his evidence was on Monitor's reaction to the launch of the Healthcare Commission investigation into the problems at the Mid Staffordshire Trust. The inquiry heard that Monitor has the regulatory power to remove management, but despite mounting evidence, they decided not to use that power until after the release of the HCC's official report. They began using their regulatory powers two weeks before it was released, by which time both the chairman and chief executive had stepped down. Mr Lavelle did say however that they had been putting pressure on the management to sort things out before officially intervening.
24-25 May: David Hill, Senior Assessment Manager at Monitor
David Hill was part of the team which decided whether the Mid Staffordshire Trust should be awarded foundation trust status. The inquiry heard that the focus of the assessment had been finances and the way in which the trust was run, rather than clinical issues. That meant they didn't request information such as patient and staff surveys, which at the time of the application, were both quite negative. Mr Hill also said that they didn't meet with patients during the process or carry out a detailed investigation into the trust's apparently high death rates. He told the inquiry that Monitor's assessment procedure has now changed, and there is now a greater focus on the quality of care.
24 May: Miranda Carter, Assessment Director at Monitor
Miranda Carter oversees the assessment of all trusts applying for foundation trust status. She told the inquiry that they relied on the annual rating systems of the Healthcare Commission to highlight any problems in care, and that they weren't in regular contact because they didn't want to duplicate the work of the HCC. She admitted that the focus of assessment was on the structure of the organisation, and that when high death rates were highlighted at the trust, they were more concerned that there was an action plan in place to sort it out, than patients who were dying when they shouldn't have been. Ms Carter said that they work closely with the Care Quality Commission, and that she hopes the current system Monitor uses will stop something like the failings at Mid Staffordshire happening again.
19 May: Cynthia Bower, Chief Executive, Care Quality Commission
Cynthia Bower defended the way that the CQC carries out inspections. She said that all of its inspectors are trained as regulators, and the inquiry heard that very few of them have a clinical background. Miss Bower denied this was a problem because there were several experts to give advice if the inspectors needed help. She also defended the review of inspections which could lead to fewer planned inspections. In 2012 the CQC will also take on the role of scrutinising GP surgeries with no extra funding, although Cynthia Bower did say that if they needed more money they would go to the Department of Health and ask for it.
18 May: Richard Hamblin, Director of Intelligence, Care Quality Commission
Mr Hamblin's evidence focused on the way that the CQC collects its information and how it is processed. He told the inquiry that he believed if the Healthcare Commission had they systems available to them that the Care Quality Commission uses now, then inspectors would have been sent into the Mid Staffordshire Trust nine months earlier in 2006. He also said that as a result of the inquiry they were now receiving all letters sent by Coroners to NHS organisations.
17 May: Amanda Sherlock, Director of Operation Delivery, Care Quality Commission
Amanda Sherlock revealed that in January 2010 they CQC considered not registering the Mid Staffordshire Foundation Trust. This followed the management's admission that they had not met five of the sixteen essential standards that it was required to by the Government. If this had happened it would have led to parts of the Hospital being closed. Mrs Sherlock said they decided it against it because of the impact it would have on other local health services.
16 May: Roger Davidson, Former Head of Media and Public Affairs, Care Quality Commission
Roger Davidson, joined the CQC from its predecessor the Healthcare Commission where he was the Head of Communications. He told the inquiry that when the HCC published its report on the Mid Staffordshire Trust he had was in favour of including the estimated of the number of people who had died as a result of their treatment. He believed it should be made clear that it should have come with an explanation as to how they had come up with the figures. They were removed from the final report because the Chairman of the HCC wanted the focus to be on the standards of care. The Inquiry was told that there was pressure to take them out from the Department of Health.
4 May: Professor Sir Ian Kennedy, Former Chairman Healthcare Commission
Sir Ian Kennedy told the Public Inquiry that there was constant political pressure on his organisation but he always managed to resist it. He said that he was unimpressed by the national standards handed down to him by the Government, and that it took several years for the HCC to find its feet. Sir told the inquiry that the decision to remove the estimation of the number of people who had died at the hospital was his as he wanted the focus to be on the "appalling" care. He also didn't want people thinking that there relative was one of the 400-1200 when it couldn't be proven.
20 April: Elizabeth Buggins, Chairman of the NHS West Midlands Strategic Health Authority
Elizabeth Buggins joined NHS West Midlands when it was formed in 2006. She said the reorganisation had "huge practical consequences" and that the handover process wasn't "done in a coordinated way that would have raised concerns around [Stafford Hospital]". She did however say that concerns were raised about other hospitals in the region. The inquiry also heard that she had considered resigning over what had happened at the hospital but was persuaded not to by colleagues. But Mrs Buggins denied that there had been a serious failure within the Strategic Health Authority, and said that her organisation "had learnt some very serious lessons" from what had happened at the Mid Staffordshire Trust.
18-19 April: Cynthia Bower, Former Chief Executive of the NHS West Midlands Strategic Health Authority
Cynthia Bower was Chief Executive of NHS West Midlands from July 2006-August 2008, before becoming the head of England's largest health watchdog, the Care Quality Commission. Ms Bower apologised for the failing to pick up on the problems at the hospital but denied that there had been a "serious failure" by the Strategic Health Authority. She told the inquiry that no other organisations had raised concerns, although she did admit that they had missed some of the signs which could have suggested that there was a problem. The inquiry heard that at the time things were going wrong at the Mid Staffordshire Trust, there were other hospitals which the SHA believed represented a "bigger risk".
12-13 April: Steve Allen, Former Head of Planning and Information NHS West Midlands Strategic Health Authority
Steve Allen's evidence focussed on the SHA's response to a report which suggested that the Mid Staffordshire Trust had abnormally high death rates. He told the inquiry that it was one of six in the region which were named in the report by Dr Foster Intelligence. Mr Allen told the inquiry that in 2007 the Mid Staffordshire Trust was one of six in the West Midlands to have higher that average Hospital Standard Mortality Ratios. He said that the SHA wanted to know the reason behind the figures, as it could have been misinterpreted, and so he commissioned a report into how Dr Foster had compiled them. This did not include going into any of the hospitals. Mr Allen said that in hindsight, he believed that at the time there should have been a full clinical investigation at all the hospitals highlighted in 2007, although that didn't happen. None of the other trusts appeared to have a problem with the standards of care though.
1 April: Alex Fox, Chairman, South Staffordshire Primary Care Trust
Alex Fox joined the PCT when it formed in October 2006. He told the inquiry that it has "over a thousand contracts we have to monitor" which made it difficult to spot trends in a single organisation. He also said it would not have been his expectation that managerial teams would be "perfectly capable" of running their own affairs. But Mr Fox said that he believed that the contracts they were handing out at the time were "unenforceable" because they didn't have the relevant powers to do anything if there was a problem.
He was also asked about the Mid Staffordshire Trust's application for Foundation Status which the PCT endorsed. He told the inquiry that at the time there was no evidence to suggest there was a problem at the hospital. But following the approval of the application Mr Fox said the Trust's Chairman Toni Brisby made it clear that they wanted a "working relationship and not a regulatory relationship" and that "the trust generally took on the mantle that they were untouchable", but she was reminded that the PCT still needed to ensure that services were adequate. Following the release of the Healthcare Commission report the Primary Care Trust had a meeting with Monitor and the Hospital's Interim Chairman and Chief Executive saying they needed "hands on assurances" about governance. Mr Fox claims the response was that that they had no role in managing the hospital and "they were essentially saying get your tanks off my lawn".
30-31 March: Yvonne Sawbridge, Director of Quality and Nursing, South Staffordshire Primary Care Trust
Yvonne Sawbridge joined the PCT shortly after it was formed, but she said that none of the four local Primary Care Trusts it replaced raised any concerns about the Mid Staffordshire Trust. The inquiry heard that it took around 18 months before the South Staffordshire PCT established a way of measuring the quality of local health services, and that is wasn't until 2008 that locally-based targets began to appear in contracts. Mrs Sawbridge was also invited to be part of an executive group at the hospital, but failed to pick up on a report which had found serious problems in the General Surgery Department. She told the inquiry that nobody had raised the report before the meeting and that she was under the impression that it was being dealt with by the management. When a report in 2007 highlighted unusually high death rates, Mrs Sawbridge said that Stafford was not the only trust with an issue within their area, and so they accepted the management's claims that it was down to the way the data was recorded. They did however commission a review of the Stafford Hospital data in 2008 which suggested those claims were unfounded.
In April of that year the PCT met with the campaign group Cure the NHS for the first time, and they alerted them to issues at the hospital. The PCT also carried out an unannounced inspection of the hospital which highlighted staffing issues in A&E, and despite mentioning some quite serious problems, it concluded that there were "no specific concerns about the trust being an outlier in the quality of services which they deliver". Five months later they did contact the hospital with concerns about the standard care in the department. Mrs Sawbridge also apologised for missing the problems at the hospital saying "if we'd put the jigsaw together sooner that would have been preferable".
29 March: Geraint Griffiths, Acting Chief Executive, South Staffordshire Primary Care Trust
When Geraint Griffiths joined South Staffordshire PCT in November 2006, he was the lead commissioner of health services for the Stafford area. He told the inquiry that no concerns were raised about Stafford Hospital at the time they took over, and that previous indicators that there could have been a problem were not included in the handover process as it was assumed the problems had been sorted out. The inquiry heard in 2007 that there were concerns about the Accident and Emergency department missing its four-hour target for waiting times. Mr Griffiths said it didn't alert them to any potential problems with staffing levels as it was thought the problem was down to a blockage in other parts of the hospital. The inquiry was also told that the PCT struggled to get certain information out of the hospital management, and that they had to include all of the documents they wanted access into the contracts between the two organisations.
28 March: Dr Helen Moss, former director of nursing at Stafford Hospital
Dr Moss worked at Stafford between December 2006 and November 2009. She told the inquiry that, in hindsight, she did not make the problems over nursing staff clear enough to the board. The inquiry heard from a report published in March 2008 which showed that Stafford was 120 nurses short of what it could have employed. The hospital trust invested £1.7m in recruiting new nurses, but Dr Moss said although the funding was there, recruitment was slow and at times only eight out of 10 nurse shifts were filled.
23-24 March: John Newsham, Former Director of Finance and Deputy Chief Executive, Mid Staffordshire NHS Foundation Trust
John Newsham told the inquiry that the Trust's initial financial problems were caused by several factors, including a change to consultant contracts, changes to European laws on working hours, and a historic deficit. The inquiry heard that managers came up with an action plan to balance the books which included closing 180 posts, although a final decision would be made by a review board. In the meantime those posts were being filled by agency staff. In August 2005 the board decided that they were too expensive and so stopped using them except in certain circumstances. Mr Newsham admitted that this could have led to staff shortages.
The inquiry also saw a letter from Sir David Nicholson who was head of the West Midland's Strategic Health Authority who made it clear they had to break even by the end of the financial year. In May 2006 the Hospital decided it needed to save £10m, so the number of jobs which and so they decided to axe an additional 170 jobs. That took the number of posts which were to be lost or closed to 330. The inquiry also heard that there had been several reports of problems of staffing levels but Mike Newsham said none of them were raised with him. He retired in 2008 after the Mid Staffordshire Trust gained Foundation Status.
22 March: Val Suarez, Former Medical Director, Mid Staffordshire NHS Foundation Trust
Val Suarez joined the Trust in 1989, and became its Medical Director in 2006. She told the inquiry that nobody had raised concerns with her about the quality of service or staffing levels in A&E when she took over. In October 2006, the lack of senior medical cover in the department was highlighted at a Trust Board Meeting. It was decided that the quietest times (overnights Monday-Thursday) would be covered by junior doctors with a consultant on call. Two consultants were finally recruited in September 2008, although she told the inquiry that there were "personality difficulties in the department which was putting people off applying".
She was also asked about a Royal College of Surgeon's report which highlighted serious problems in the General Surgical Department in 2007. Dr Suarez told the inquiry that she didn't involve the General Medical Council because she needed more evidence. It is not clear whether the Strategic Health Authority or South Staffordshire Primary Care Trust knew about it either. As a pathologist, Dr Suarez dealt a lot with the South Staffordshire Coroner Andrew Haigh, and she said that she believed that he wasn't accepting some of the cases which she believed had been referred correctly. She concluded her evidence by apologising for the "lack of care" provided by the Trust.
16 March: Anthony Sumara, Chief Executive of Mid Staffordshire NHS Foundation Trust
Anthony Sumara first came into contact with Stafford Hospital in 2005 when he was managing director of the now defunct Shropshire & Staffordshire Strategic Health Authority. He was part of a panel which had to assess whether the Mid Staffordshire NHS Hospital Trust was suitable to gain Foundation Status. It later concluded that the trust was at least two years away from being ready to apply, although in his statement he said there were no obvious issues, but that he felt no pressure to put forward trusts for FT status.
In 2009 he was appointed Chief Executive of the Mid Staffordshire Trust and the inquiry heard from him that there was a "definite reluctance on the part of any members of staff to accept responsibility for their actions." Two days after he arrived at the hsopital he told the executive team that they "didn't have a clue what they were doing" during a meeting which had not seemed to address any of the major issues facing the hospital. He also expressed surprise that more people had not resigned over their part in the hospital's failings. When asked about the official regulators, Antony Sumara raised concerns about whether they would be in any more of a better position now to spot another Stafford Hospital; he concluded that they probably would not.
15 March: Eric Morton, Chief Executive of Chesterfield Royal Hospital NHS Foundation Trust
Eric Morton was the interim Chief Executive of Mid Staffordshire NHS Foundation Trust between March-July 2009. He spent around four days a week at the trust. The inquiry heard that when he was appointed the outgoing chief executive Martin Yeates was still employed by the trust and was hoping to gain further employment within the NHS.
Mr Morton said that he was surprised that when he arrived that there was not a specific committee to look at the quality of care being provided by the trust. He also told the inquiry that he was not sure that the trust should have been considered for foundation status. Previous witnesses had claimed his reaction to the hospital's failings showed that he had the same attitude as the previous management, but he denied that, citing the fact that the trust had offered a very clear apology when the Healthcare Commission report was released.
14-15 March: Mike Gill, former Finance Director of the Mid Staffordshire NHS Foundation Trust
Before working for the Mid Staffordshire Trust, Mike Gill worked for Monitor (Oct 04 - Nov 06) helping to develop the assessment process for Foundation Trust (FT) status, before moving to the Department of Health (Nov 06 - July 08) to oversee all FT applications "north of Watford".
He told the inquiry that when it came to assessing whether a trust was suitable to gain FT status, Monitor looked purely at the financial side of things, while the Healthcare Commission (HCC) looked at the quality of care. The inquiry heard him say that the HCC did not raise any concerns about the hospital, and did not copy him in on any future correspondence that highlighted its concerns.
He was also part of a 'diagnostic board' which looked at whether Mid Staffordshire was ready for FT status; and it concluded it needed at least two years. The West Midlands Strategic Health Authority did however put it forward, and in May 2007 Mr Gill said he wrote an e-mail saying because of financial issues the application was "unsupportable". Documents from the Department of Health seem to suggest his mind was changed by the trust which had come up with a financial plan. But in June 2007 a Department of Health assessment panel had considered a report which said that the "application was difficult to support". Mr Gill said that it was a "borderline application" and that the panel had felt it would be able to sort out the problems before it was finally assessed by Monitor. The application was later allowed to proceed by former Health Secretary Andy Burnham who was a health minister at the time.
9 March: David Stone, former Interim Chairman of the Mid Staffordshire NHS Foundation Trust
David Stone, who is now the Chairman of Sheffield Teaching Hospitals NHS Foundation Trust, was asked by Monitor to be the Interim Chairman of the Mid Staffordshire NHS Foundation Trust in February 2009. He told the inquiry that at the time the regulator was effectively running the hospital. Mr Stone said he met the then Chief Executive Martin Yeates who told him "he felt that clearly there had been deficiencies" - but that he got the impression that he "was taking actions to put them right".
Mr Stone said that when he visited the hospital it was clear that Mr Yeates could not stay in post, but he refused to resign. A report was commissioned to see whether he could be dismissed, which concluded that he could, but that such a move might end in legal action. Mr Stone told the inquiry that he took the decision to persuade him to step aside with a settlement because "they needed to move the agenda forward".
David Stone left the post in July 2009 following the appointment of Sir Stephen Moss.
8 March: Dr Peter Carter, Director General & Chief Executive of the Royal College of Nursing
The inquiry heard that Dr Carter visited the hospital on May 23, 2008. The visit lasted about three hours during which time he toured some of the wards, as well as meeting with RCN members, patients and management.
Following that visit he wrote a letter to both the hospital and the local press praising Stafford, saying how well managed it was. He told the inquiry that he was not briefed about the hospital before he went in, saying that "nothing raised my antennae that there were problems", and that he would have been "reliant on people to proactively bring it to my attention". Dr Carter said that even at an open forum with his members nobody had told him things were going wrong because they had said "they didn't know". He also said he did not know there had been 150 job losses the year before, or that the Healthcare Commission was carrying out an investigation into the problems there.
When asked whether he regretted sending the letters he replied that he did not, because he had written them in "good faith" and that if he had have spotted any issues he would have raised them. He did however concede that he should have been more precise about which wards he had visited, and that three hours was not long enough to tell if it was "well managed".
2 March: Dr Chris Turner - former Clinical Lead for Emergency Medicine at Stafford Hospital
Dr Turner joined the Mid Staffordshire Trust in October 2007. He described the Accident & Emergency Department as a "disaster" and the worst he'd ever seen in 25 years in the NHS. He told the inquiry that there was a culture of bullying and harassment, particularly of nursing staff, and that they were exposed to more managerial pressure than you would normally expect. He described seeing nurses in tears after meetings about targets, while others were threatened with their jobs if those targets were not met.
He also had several meetings with the former Chief Executive Martin Yeates. During one he complained about the fact that consultants from different departments were taking on jobs in A&E - but he did not get an answer from him.
He also spoke to the Healthcare Commission about the problems there. He described another meeting with Mr Yeates, in which he raised concerns about the department. Dr Turner said: "I could tell it came as a surprise to him just how dire the perception both internally and externally of the department was."
He was made clinical lead of the department in December 2009; and the inquiry heard that he then set about making changes, and that there was then less pressure from the new management to meet targets.
28 February: Andrew Haigh, South Staffordshire coroner
Andrew Haigh told the inquiry that Stafford Hospital was not the only hospital or health care institution under his jurisdiction. He also said he did not identify a systemic failure because he was dealing with individual cases, and that in 2008 he was more concerned about the Queen's Hospital in Burton, because he was getting more complaints about it.
Mr Haigh did say that families of those who died would raise concerns about staffing levels at Stafford but he would rarely raise them with the hospital because of the "resource issues".
In October 2006 he did write to the trust about matters but, after six months and several letters, he still had not had an answer. He wrote 14 reports to the hospital between 2005 and July 2008 and in that time the hospital did not respond to four of those reports.
He also said he did not check up on whether they had actually acted on his concerns, but he also was not required to. Mr Haigh did say however that: "I was still carrying out my role within the legislation, so essentially I was still doing my job."
From Monday 21 to Friday 25 February the Stafford Hospital Inquiry was in recess
10 February: Kath Fox, Bereavement Officer and UNISON Representative at Stafford Hospital
Kath Fox told the inquiry that as early as 2005 concerns were being raised in the corridors about staff shortages but she said that she didn't receive any formal complaints because nobody "felt confident enough to raise their head above the parapet". Mrs Fox also told the inquiry that she could tell that there was a staff shortage on the wards because the number of deaths "did appear to go up". When she spoke to senior management about it she was made to feel "worthless" and as if her "opinion didn't really matter".
She also raised concerns about the way death certificates were filled out by junior doctors. Mrs Fox claimed that from what she could hear of the phone conversations with the Coroner's office, she felt they were pressurised to give a cause of death, even when they weren't sure of what it was, and so there should have been a post mortem examination. When asked why she didn't escalate it with her union, she said she had to keep her roles as a union rep and bereavement officer separate. And although she raised it with other reps, and at meetings, she didn't go into much detail, and "was in fear of repercussions" if she went too far.
8 February: Janet Eagland, Chair of Staffordshire County Council's Health Scrutiny Committee
Janet Eagland became the chair of Staffordshire County Council's Health Scrutiny Committee in 2009. She told the inquiry that since being a councillor she had not received any complaints about any of the county's hospitals. Mrs Eagland said her committee had no background knowledge of the health service and they relied on the managers they questioned to tell the truth, although she was unaware that they could bring in experts from outside to help them.
She said that her relationship with the current management was "a lot more open" and that they had an "open invitation to visit the hospital" to inspect it. The committee has also started up a meeting involving all of the councils in the county which will allow them to question local health officials. But when asked how she knew that the present chief executive Anthony Sumara might not be also "spinning them a yarn", she said that "we again rely on honesty".
Mrs Eagland did however apologise to relatives of those who died at the hospital saying that: "I feel very humble that I haven't done more to represent them".
4 February: Bill Cash, Conservative MP for Stone
The inquiry was shown a cover letter sent from Bill Cash to the then Health Secretary Patricia Hewitt in 2006, which was attached to a complaint about Stafford Hospital. Mr Cash stated that this is what he did with complaints he received about Stafford Hospital; and that the aim was to "alert at the highest level my concern". He told the inquiry that he believed by sending it to the top it would be sent to all of the relevant departments, although he did not raise the complaints with anybody else.
Mr Cash was also asked how many times he had visited the hospital between 2003 and 2008 and he said he couldn't recall. When asked about why he did not respond to a consultation letter about the trust achieving foundation status he said he did not feel he had the expert knowledge required to give his opinion.
In 2008 he was visited by Julie Bailey and Deborah Hazeldine from Cure The NHS. From that point he said he called for the hospital to be put into special measures and be subjected to a thorough investigation. He also raised several questions in Parliament and said he was a staunch supporter of the campaign for a public inquiry, as he had little faith in the regulatory bodies.
3 February: David Kidney, Stafford Labour MP during 1997-2010
David Kidney told the inquiry that in 2006 it emerged that the hospital had a financial deficit of £6m, and the then Chief Executive David O'Neill told him that savings of that magnitude would not be achievable, and that it would be equivalent to shutting down Cannock Hospital.
He said that he met Health Minister John Hutton but the meeting came to nothing. When Martin Yeates took over as Chief Executive Mr Kidney says he was told that the Trust would need to save £10m, and that 160 staff would have to go, but he was assured that no nurses would lose their jobs. He was under the impression that it would be achieved by cutting management and back office staff.
Speaking about the time that Julie Bailey wrote to him in 2008 about the problems at the hospital he said, "I thought it required a lot of attention and a lot of work", but that he kept pushing the management to recruit more nurses. He says he was told that they had employed 50 nurses in the summer, and 100 more by the autumn. He later said that that may not have been the case.
In September 2008 he had a meeting with hospital managers about the Healthcare Commission report in which they were warned the results would be negative. He claimed he did not realise how bad it was going to be; and that he was "affronted" that he had not been sent a copy of the draft report.
1 February: Professor Tony Wright, former Labour MP for Cannock Chase, told the inquiry that he'd had concerns about Stafford Hospital in the 1990s when he felt there was "serious leadership issues" mainly because of the "recurrent financial problems". He also said an ambulance driver had told him they tried to avoid taking patients there. The inquiry also heard that he'd "received a stream of complaints" about local health services.
Despite this, he denied knowing that there was a systemic failure at the hospital, or the scale of the problems on the wards until the release of the Healthcare Commission Report in 2009. He also said that he did challenge the former Chief Executive Martin Yeates on any problems which were raised, although Mr Wright refused to be drawn on whether he accepted what he was being told. He did admit though that he was "deeply disappointed when it all came out". He retired from political life at the last election.
31 January: Christine Baron, member of the Stafford Borough Health Scrutiny Committee, told the inquiry no members of the public had come to her with any complaints about the hospital before the end of 2007. She herself had been a patient in 2008 and she told the inquiry that the treatment she received had saved her life.
She admitted that part of the problem was that they believed that the former management at the hospital were telling them the truth. Councillor Baron was asked if she'd read the reports into the problems at the hospital and she admitted that she hadn't, but told the inquiry that "I have confidence myself that progress has been made" before saying. " I haven't got factual evidence that it's been made. What I have got is belief".
27 January: Councillor Phillip Jones, who is both on Stafford Borough Council and Staffordshire County Council, as well as being a former governor of the hospital, was called to give evidence - because he is a member of both the Health Scrutiny Committees for the borough and county councils.
He told the inquiry that there was confusion over which council should be scrutinising Stafford Hospital. He said he wanted clarification from the county council over which areas of the hospital he should be scrutinising, but it never materialised, he claimed, because there was only "an informal agreement".
He said that meant that he only focused on certain areas - whilst it was possible others went unchecked. He said that in 2010 it was decided that the county council should be responsible for scrutinising the hospital. However, he thought he had agreed with the chairman that the borough would do it.
19 January: Dr Greaves, GP at Gnosall Surgery near Stafford, said that he had personal experience of the hospital after being admitted in 2005 and wasn't impressed by his treatment. He told the inquiry that as a result he'd worked with the hospital to try to improve communication between staff and GPs. He was treated there again in 2008 and said his experience was much better, and he wrote to management complimenting them on his treatment.
When asked why he didn't pick up any problems he told them that he'd had just six complaints in six years and that he didn't see a pattern emerging, even though two of those complaints were serious. He did however admit that he wouldn't be comfortable raising concerns with outside organisations because it might affect his relationship with the hospital.
18 January: The inquiry heard that Dr Wilson worked some shifts in the Endoscopy department of the hospital alongside his practice work. He says that as early as 2002, he'd heard there were issues with staffing levels but dismissed them as "hearsay". He was told by senior members of staff that "there isn't a lot which can be done about it", although he didn't discuss the issues with his fellow GPs.
Dr Wilson was also the Chairman of the Stafford Sub Committee of GPs and he says none of the members ever raised concern about "quality of care issues at the hospital". He told the inquiry that his mother had been treated there for a stroke and had received good treatment, adding that it was "very sad that Stafford's been picked out for specific treatment" claiming "there is an issue with regards to the quality of care generally throughout the National Health Service that needs to be addressed".
17-18 January: Sharon Llewellyn, former Customer Services Manager at Stafford Hospital, told the inquiry that she had been sidelined by hospital management and that her department was understaffed. She claimed that she had raised concerns about changes to the complaints system but they were ignored.
At one point Mrs Llewellyn said the department had been moved off the hospital site, although it has since returned. When asked what she did when she noticed that the same things kept appearing on action plans and nothing seemed to be done about it, she said she raised concerns with her line manager but didn't take it any further.
11 January: Linda Seru, former director of the hosting service for Staffordshire LINk.
Linda Seru took up the job as host director for Staffordshire LINk in September 2008. She told the inquiry that her department was understaffed, and that the way the watchdog was organised made it very difficult to run. The inquiry heard that members were only concerned about their own area and, when the problems at Stafford Hospital were raised, some pointed out that there were "other hospitals in the county".
Mrs Seru said that when Cure The NHS turned up at one of the meetings she could not act on their concerns straight away because they had to follow procedures, and that it was supposed to be about deciding the structure of the group. She also claimed that infighting amongst members meant that they struggled to make decisions. Problems persisted and in March 2009 she offered to give the contract back, but the offer was turned down by Staffordshire County Council. Later that year the contract was terminated, and the County Council decided to bring it in-house.
Despite the problems Mrs Seru maintains that the University did a good job in hosting the LINk and they currently run the service in Telford and Wrekin.
12 January: Jackie Owen, host of Staffordshire LINk
Jackie Owen joined Staffordshire LINk in September 2009, and was taken on by Staffordshire County Council when it took back the contract. She told the inquiry that the group was disbanded and they ran a consultation on the way it should be structured. In the end they decided to go for a county-wide board where volunteers were appointed and given certain roles.
Since starting her job she says has spent a lot of time contacting local organisations, and that they work closely with the Care Quality Commission. But she told the inquiry that she had struggled to organise meetings with management at Stafford Hospital. It also emerged that, despite having the power to carry out so called 'enter and view visits' on the hospital and other health organisations, they have not carried one out since it was formed - as the relevant agreements and people were not in place. She did say that the first visit will take place in 2011.
19 December: Campaigners say they are disappointed by the number of people visiting the public inquiry. On an average day, around a dozen members of the public have been listening to evidence. Cure The NHS, which campaigned for the inquiry, are urging more to come along.
17 December: After six weeks of evidence, the inquiry breaks up for Christmas. BBC Radio Stoke reports that between April and October the public inquiry has cost just over £1.4m.
15 December: Just three medical staff were referred to regulators at the height of the troubles at Stafford Hospital. This number came from a Freedom of Information Request by the charity Action Against Medical Accidents.
8 December: The Stafford Hospital public inquiry has been told that "the general culture there was all about money". Nicola Monte, who has been treated there several times since 2004, claimed on more than one occasion staff brought up the cost of her treatment.
3 December: The watchdog which exposed the problems at Stafford Hospital, knew there were issues a year before they launched an investigation. Robin Bastin claims someone at the Healthcare Commission told him infection control measures were "dire". That was at the beginning of 2007 and they started investigating in 2008.
1 December: Terry Deighton tells the Stafford Hospital public inquiry that he was sent a threatening letter after going to the press about failings there. Terry was on the public and patient involvement forum, which monitored the hospital. He said hospital solicitors wrote to him and said if he went anywhere near the site, he could be prosecuted.
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23 November: Julie Bailey tells the public inquiry that she still has "huge concerns" about patient care.
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22 November: Julie Bailey told the public inquiry that her 86-year-old mother Bella was left in a chair with no oxygen supply due to no nurses being available to reconnect the canister. She later died at the hospital. Ms Bailey described the ward as "chaos".
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15 November: First witness due to give evidence to the public inquiry.
8 November: Public inquiry chairman Robert Francis gives his opening statement.