The Healthcare Commission’s report into the problems besetting the Mid Staffordshire NHS Foundation Trust is there on the public record for all to read. Triggered by apparently high mortality rates in patients admitted as emergencies to the trust since April 2005, the 176 page report is, as always from the Commission, a comprehensive, well written and carefully structured document.

Its final recommendations are clear and simple; among other things the trust must:

• Collect and report clinical information accurately and in sufficient detail;

• Identify and mitigate risks to patient safety;

• Identify correctly, report, investigate and learn from serious incidents and unexpected deaths;

• Engage clinicians and develop effective clinical audit;

• Continue to recruit extra nursing and medical staff, so that patient care across the trust, including nights and weekends, is safe and to accepted standards;

• Review the training and supervision of its nursing staff and junior doctors, so that they can perform appropriate roles and are confident about expectations placed on them;

• Ensure

  • adequate theatre sessions to handle emergency demand;

  • adequate advice and …