CQC in the Dock
NHS England has confirmed there will an ‘inquiry in public’ into the serious systemic failures at University Hospitals of Morecambe Bay Foundation Trust (UHMBFT). But will it have the balls to expose yet more failings in the regulation and leadership of the NHS? The inquiry was sparked by the avoidable death of baby Joshua Titcombe at Furness General Hospital in November 2008. Joshua had a low temperature due to lung infection that would have been easily treatable had it been diagnosed. Sadly, it wasn’t. Joshua’s crucial observation chart disappeared soon after his death, despite ‘extensive’ searches, leading the coroner to deduce, 32 months later, it may have been ‘deliberately destroyed.’ He concluded there was a ‘very worrying mark of suspicion hanging over the maternity unit at Furness General Hospital (part of UHMBFT)’ and identified ten serious failures. A previous review into the service had also found serious failings. So why did the Care Quality Commission not investigate?
Whistleblowing CQC board member Kay Sheldon recently accused the CQC of registering failing hospitals as safe to avoid another public scandal such as Mid Staffordshire. ‘It seems to me that CQC gave assurance about the Trust that wasn’t actually accurate…It was a very shocking thing to find, thinking that an organisation that’s there to protect patients had effectively given what amounted to false assurance and that meant that problems in the Trust carried on unacknowledged and unaddressed.’
James Titcombe, Joshua’s father, works in the nuclear industry and knows a thing or two about safety: ‘The idea that any regulator could deliberately give false reassurances about the safety of vulnerable people is deeply shocking. Could you imagine the Civil Aviation Authority knowing about significant safety issues in a type of passenger jet, but then deliberately suppressing the concerns? What would happen in these circumstances if a plane subsequently crashed and hundreds of people died as a consequence?’
At Morecambe Bay, following the ‘all clear’ registration of the Trust by the CQC’, the Dr Foster unit at Imperial College London calculates that 415 excess deaths may have occurred (up to and including 2012). In 2011, the statistical estimate was more than 257 excess deaths (the highest mortality rate of any Trust in the country).
Titcombe has meticulously and courageously unearthed documents which unequivocally show the serious concerns CQC had about Morecambe Bay as far back as September 2009. At this time, the Health Service Ombudsman was considering undertaking her own investigation into concerns regarding the Trust’s maternity services, including the death of Joshua. During this process, a discussion took place between the deputy Ombudsman (Kathryn Hudson) and the regional director of the CQC (Alan Jefferson). Ms Hudson recorded details of the conversation which she forwarded to the Ombudsman, Ann Abraham. It revealed clear evidence of systematic failure in maternity services across the Trust, and serious concerns about how the entire Trust operated1. And yet in February 2010, Abraham refused to investigate, saying it was the CQC’s job to address failures, and two months later, CQC registered Morecambe Bay ‘without conditions and with no planned investigations’.
The scandal also implicates Mike Farrar, who was CEO of the North West Strategic Health Authority between July 2006 to October 2011, and is in the running to succeed Sir David ‘No Accountability’ Nicholson as chief exec of NHS England. Farrar’s partner, Rosamond Roughton, is the Director of Commissioning Development at NHS England. That shouldn’t obstruct a thorough ‘inquiry in public’.
1 www.morecombebayinquiry.co.uk