Actions of CQC questioned over investigation into Morecambe Bay Trust

Dated:

In November 2012, the CQC announced that it was commissioning an external investigation into its handling of events surrounding Morecambe Bay Trust. This investigation was reported in the Health Service Journal (HSJ) in December last year.

However, the report did not address the actions of the CQC in the months prior to the registration of Morecambe Bay Trust in April 2010, and in particular the claim that its former chief executive Cynthia Bower tried to discourage the health service ombudsman from investigating concerns about University Hospitals of Morecambe Bay Trust.

A father, whose son died in the maternity ward at Morecambe Bay’s Furness General Hospital in October 2008, used the Data Protection Act to obtain a memo written in September 2009 by deputy ombudsman Kathryn Hudson to Ms Abraham. The documents obtained suggest Ms Bower and Ms Abraham discussed whether the ombudsman needed to investigate the boy’s death.

The alleged conversation raises questions about the closeness of the 2 regulators. It took place at a time the CQC was under pressure months after the Mid Staffordshire scandal emerged, amid fears of systemic failings across the wider NHS.

A boy died from a lung infection that could have been treated with antibiotics after staff dismissed his father’s fears about the standard of his care. His death was one of a number at the hospital’s maternity department, which was heavily criticised by the CQC following an inspection in July 2011. This was only a year after the CQC registered the trust without conditions.

The CQC therefore appointed the consultancy Grant Thornton to look into the following allegations:

  • That in the summer of 2009, the previous CQC CEO allegedly engaged in an improper discussion with the chief PHSO in an attempt to influence the PHSO's consideration of whether to investigate further a complaint that had been made to it by the child's father concerning the care given to his wife and new born son by UHMB. The alleged improper discussions took place not long after the CQC had decided not to investigate a cluster of maternity Serious Untoward Incident’s (SUIs) that had occurred at UHMB in 2008, one of which was the Baby T case;
  • That following the CQC’s decision not to investigate the 2008 cluster SUI's and notwithstanding an apparent acknowledgment in the latter part of 2009 that there were serious and systemic risks to patient safety at UHMB: CQC wrongly de-escalated its risk profile of the Trust in the months leading up to its regulatory registration on 1 April 2010. It is contended that this de-escalation ultimately resulted in the Trust achieving registration without the imposition of any conditions for improvement. The consequence of this was that the public was given a misleading impression of patient safety at UHMB, particularly in relation to maternity services.
This additional investigation carried out by Grant Thornton should cover the time period May 2009 to April 2010, which is the period during which the events giving rise to the complaint allegedly occurred. This additional element of work shall be termed 'Phase Two'. Three key questions that we aim to answer as a result of our work are as follows:

  • Having had concerns about maternity services in December 2009, on what basis did the CQC subsequently register the Trust without conditions in April 2010?
  • Did the CQC make its own independent decision about what action to take following an investigation case referral from CQC's North West regional team in 2009, which concerned 5 Serious Untoward Incidents that occurred at University Hospitals Morecambe Bay maternity services in 2008, one of which involved a boy's death?
  • What was the nature of the CQC’s subsequent interaction with the PHSO and what evidence is there regarding the claim that the CQC’s former Chief Executive tried to influence the PHSO not to investigate a complaint about Morecambe Bay maternity services?
The boy's father told HSJ: "It is absolutely clear at the time the CQC had told [then health secretary] Alan Johnson that Mid Staffs was a one-off and the CQC was being criticised for Mid Staffs and so the last thing they wanted was another hospital scandal."

"I believe concerns were suppressed and an investigation into my son's case was suppressed for political reasons."

A spokesman for the ombudsman's office said: "There is no substance to these allegations. The decision on whether to investigate any case is ours alone."

The Grant Thornton report will be published next week and it is understood that the Care Quality Commission board will be told of a catalogue of failings into its oversight of the University Hospitals of Morecambe Bay Trust, in Cumbria. The report will be a major landmark for the NHS, coming after the damning Francis report.

It is to be followed by a full independent inquiry, in public, into the care of mothers and babies at the trust and a separate police inquiry into the deaths of 8 babies, including the child mentioned above, has also been launched.

Jackie Daniel, chief executive of the trust, said the hospitals had "badly let the public down in the past, but that staff were working hard to put things right". She went on to say that the Trust had made significant progress in the last 12 months and all warning notices on the organisation were now lifted.

A spokesman for the CQC said the organisation would consider the findings of the report when it was given to the board.

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