The Francis Inquiry

Assuring patient safety and quality across the system of care
The King's Fund

About this event

Featuring Robert Francis QC, this conference looked at the outcomes and implications of the Francis Inquiry report.

You can download the speakers' presentations from the presentations tab above.

Highlights from this event

Robert Francis: multimedia

Robert Francis
Robert Francis: lessons from Stafford

Robert Francis QC presents the lessons from his inquiry into care failings at Mid Staffordshire NHS Foundation Trust.

Watch video highlights of Robert's presentation
View Robert's presentation slides

Daniel Poulter thumbnail

Daniel Poulter
Daniel Poulter MP: the government's response to Francis

Dr Daniel Poulter MP, Parliamentary Under Secretary of State for Health, gives the government's response to the Francis Inquiry report.

Watch video highlights of Daniel's presentation

Ian Kennedy thumbnail

Ian Kennedy
Panel session: responses to the Francis Inquiry report

David Behan, Jill Maben, Harry Cayton OBE, Professor Sir Ian Kennedy and Peter Walsh give their reactions to the Francis Inquiry report.

Watch video highlights of the panel session

Rhona Flin thumbnail

Rhona Flin
Rhona Flin: building a safety culture in the NHS

Rhona Flin, Professor of Applied Psychology at the University of Aberdeen, discusses how we can develop and manage a safety culture in the NHS and draws on how safety is managed in other industries.

Listen to Rhona's presentation

More about the event

On 9 June 2010, Andrew Lansley MP, announced a full public inquiry into the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire Foundation NHS Trust.

Mr Francis QC presented his final report to the Secretary of State in January 2013. The report proposed far-reaching changes at all levels of the system, including to the external organisations that regulate quality, so as to ensure that gross failings of this nature do not occur again.


Breakfast seminar

Hosted by Mills & Reeve and Allocate Software

Quality – Making it happen: Practical responses to Francis from Board to Ward
A discursive breakfast seminar providing take away points with input from:

  • Professor Sir Ian Kennedy, Former Chairman Healthcare Commission
  • Elisabeth Buggins, Chair of Birmingham Women's NHS Foundation Trust
  • Lucy Connolly, Assistant Chief Nurse, York Teaching Hospital NHS Foundation Trust
  • Dr Martin Goddard, Consultant Histopathologist and Clinical Director, Pathology Services, Papworth NHS Trust and witness to the public inquiry.


Session one: A whole system response

Welcome and introduction
Professor Chris Ham, Chief Executive, The King's Fund

Keynote address: The directional steps the whole system should take to respond to the challenges highlighted by Mid Staffordshire
Robert Francis QC, Chair, Mid Staffordshire Inquiry

Panel response:

  • What are the high level principles and behaviours that the system, including government, regulators, commissioners, providers and individual professionals, must follow?
  • How can the system support the actions and effectiveness of those at the frontline and those who manage and lead organisations?


  • David Behan, Chief Executive, Care Quality Commission
  • Jackie Smith, Chief Executive and Registrar, Nursing and Midwifery Council
  • Harry Cayton OBE, Chief Executive, Professional Standards Authority
  • Professor Sir Ian Kennedy, Former Chair, Healthcare Commission
  • Peter Walsh, Chief Executive, Action against Medical Accidents

Session two: Better regulation

Welcome back
Professor Chris Ham, Chief Executive, The King's Fund

Government's response
Dr Daniel Poulter MP, Parliamentary Under Secretary of State for Health

Panel discussion:

  • How should regulators interact with health care providers and each other? How can we ensure regulation is aligned to the activities of those delivering care?


  • Dr Daniel Poulter MP, Parliamentary Under Secretary of State for Health
  • Niall Dickson, Chief Executive and Registrar, General Medical Council
  • Cllr David Rogers OBE, Chairman, Local Government Association's Community Wellbeing Board, and vice-chair of Health Scrutiny in East Sussex
  • Anna Walker, Chair, Office of Rail Regulation
  • Dr Mark Porter, Chair of Council, British Medical Association

Session three: The role of the board

Welcome back
Sarah Goodson, Senior Consultant, Leadership Development, The King's Fund

Panel discussion:

  • How can boards ensure good governance and effective leadership; that there are clear organisational and professional roles across the organisation; that care systems are redesigned to ensure a more patient-centred approach and that patients and the public can be satisfied that safety and quality is at the forefront?


  • Suzie Hughes, Lay Chair, Patient and Carer Involvement Steering Group, Royal College of Physicians
  • Sir Jonathan Michael, Chief Executive, Oxford University Hospitals NHS
  • Eric Morton, Interim Chief Executive, Sherwood Forest Hospitals NHS Foundation Trust
  • Jan Sobieraj, Managing Director, NHS Leadership Academy

Session four: Developing and managing a safety culture

Welcome back
Dr Jocelyn Cornwell, Director, The Point of Care programme, The King's Fund

Keynote address
Professor Rhona Flin, Professor of Applied Psychology, University of Aberdeen

Panel response:

  • What actions can senior leaders take to protect patients from harm? Are the roles clinicians and managers the same or different in relation to safe care? What part can patients and families play in making care safer? How can we shift from a ‘blame’ to a ‘just’ culture?


  • Dr Kathy McLean, Medical Director, NHS Trust Development Authority
  • Michael West, Professor of Organisational Psychology, Lancaster University Management School
  • Professor David Hands, Visiting Professor in Health Policy and Management, Welsh Institute for Health and Social Care, University of Glamorgan
  • Professor Norman Williams, President, Royal College of Surgeons