1. The Francis Report: Patients First and Foremost

2. Patients and families were not listened to Multiple warning signs not spotted or acted on Information not shared and inadequate action taken “The system failed in its most essential duty, to protect patients.” The Findings – What went wrong

3. The Findings – Keys themes Values and Standards Openness, Transparency and Candour Leadership Compassion and Care Information

4. Addressing the Themes The CNO’s vision and strategy for Nursing, Compassion in Practice Authorisation process for CCGs with a clear focus on quality, shaped by the first Francis report Commitments made in planning guidance, Everyone Counts Respond to the final report on Winterbourne View Organisation Development Strategy, as a key driver of cultural change The National Quality Board and the NHS Leadership Academy will play key roles in shaping the new culture Sir Bruce Keogh’s investigation into hospitals which are outliers on measures of mortality

5. Patient First and Foremost Collective Commitment Apologises for failures Commits to putting patients first and listening Commits to doing the business of the patient, before that of the organisation or the system, with a direct connection to patients and frontline staff Commits to working together to tackle poor care and promote excellent care in a spirit of openness and candour “Changing ourselves, our behaviour, individually and institutionally, is difficult, but we pledge to do so.”

6. Patient first and Foremost: Initial Response Time to Care and Space to lead Focus on Safety (Berwick Report) Preventing Problems Chief Inspectors Staff and Patient voice Ratings Statutory duty of Candour Detecting Problems Quickly Fundamental Standards Single Failure Regime Taking action Promptly HSE Powers Professional Regulation Barring Failed Managers Ensuring Robust Accountability Training Leadership Revalidation Ensuring Staff are Trained and Motivated