ABSTRACT
Why were things going wrong at Stafford and why were things going wrong in end-of-life care, an area of practice in which the UK had led the world? Was it just Stafford and just end-of-life care where there were breakdowns in care? Were there similar problems elsewhere in the National Health Service (NHS) or in local authority care settings? This introduction spells out the way subsequent chapters will examine in detail what happened, what scrutiny/quality control was in place and why failures were not remedied. The core conclusion of the lengthy reports that looked into failures in Stafford (and in other hospitals) was that something had gone wrong with the institutional culture and that making significant and lasting change required a change in that culture. How has culture change been attempted and how does it sit alongside other routes to change?
