When seen in retrospect, the warning signs detailed in the Francis Report (http://www.midstaffsinquiry.com) were obvious, it is clear that external agencies who should have acted in a regulatory fashion; the Strategic Health Authority and Monitor failed to acted in a robust fashion when the Commission for Healthcare Improvement (CHI) re-rated the Mid Staffordshire NHS Foundation Trust from 3 stars to zero. This re-rating occurred in 2004 and perhaps an enquiry at that time may have saved countless patients from unnecessary suffering. In addition, several peer reviews that took place at the Trust all identified serious concerns regarding the ability of the Trust to provide a safe service.