NHS regulator’s cover-up over baby deaths ‘unacceptable’

The Care Quality Commission (CQC) has been found to have deliberately suppressed an internal review that highlighted weaknesses in its inspections of University Hospitals of Morecambe Bay NHS Trust.

A report into what happened found that the health watchdog bosses were so concerned about how damning the review would be that they ordered it should never be made public and that it should be destroyed.

Kelly Hine, whose daughter Amelia died after the Morecambe Trust was passed safe by the regulator, expressed her dismay at the findings:

“I can’t believe that so many things were wrong at Furness General Hospital for so long before Amelia’s birth in April 2011. Maybe if they had done something, Amelia would not have died. That is a very hard thing to live with.”

(pictured: Kelly Hine and her partner Carl Scott-Bower whose daughter Amelia died at Furness General Hospital)

David Cameron’s spokesman said the government had taken strong action to reform the CQC: “What occurred was… deeply disturbing and appalling,” the premier’s spokesman said.

Speaking in the House of Commons, Health Secretary Jeremy Hunt said that the “whole truth must now come out and individuals must be accountable for their actions”.

However he said that he would not be able to say whether any of those involved in the cover-up were still working at the CQC or elsewhere in the NHS until the new CQC Chairman David Prior completed his own enquiries within the next two months to determine what sanctions were appropriate.

Speaking on Channel 4 News, Mr Prior was scathing about the CQC in past years:

“When you have an organisation which is as dysfunctional as this one, where the culture was so rotten at the top, where the relationship between the top executive and the board is so poisonous, bad things happen.”

“Frankly the responsibility for this lies right at the top of the organisation, with the board, the chairman, the chief executive.”

Following the publication of the report the MP for South Lakes Tim Farron wrote to the Metropolitan police to ask them to investigate the cover-up to see if a criminal offence had been committed.

Are you kidding me? This can never be in a public domain… One senior manager

Earlier he said “heads must roll” if the allegations are true: “These allegations are shocking and if true highlight massive failures in the system that is supposed to keep patients safe.

“I have tried to support the families affected by this tragedy for years, but this report shows that collusion could have happened at the highest level – heads must roll for this.”

‘Destroy the review’

The report, by management consultants Grant Thornton, was ordered by David Behan, who became chief executive of the CQC last summer.

It suggests that senior managers at the CQC were more concerned about protecting the organisation’s reputation than about patient care when they ordered the review to be suppressed.

Concerns about the maternity unit at the Morecambe Bay trust emerged came to light in 2008, but the CQC gave the trust the all-clear in 2010.

But when a review into maternity care was ordered the following year it was so damning it was suppressed. The Grant Thornton report reveals how a CQC official was ordered last year to destroy the critical review.

In accounts of discussions between senior managers about what to do with the findings, one senior manager said: “Are you kidding me? This can never be in a public domain nor subject to FOI (a freedom of information request). Read my lips.”

An official who carried out the review was asked to delete it and write a different review without criticism of the CQC.

‘Failure of leadership’

The report said the man felt he was “being put in a very difficult position” and was asked to do something that was “clearly wrong”.

It describes how the man “said that he felt very uncomfortable about the apparent weight that was being given in the meeting to the potential media impact and reputation damage his report findings might cause CQC. His view was that the focus instead should have been on patient safety and the protection of service users”.

University Hospitals of Morecambe Bay NHS Trust was warned in 2011 that it would be closed down without major changes.

Last night a spokesman for the CQC said the organisation’s culture was changing, saying: “We let people down, and we apologise for that.

“This report reveals just how poor the CQC oversight of University Hospitals Morecambe Bay was in 2010.

“This is not the way things should have happened. It is not the way things will happen in the future. We will use the report to inform the changes we are making to improve the way we work and the way we are run.

“There is no evidence of a systematic cover-up or of any collusion between CQC and the Public Health Service Ombudsman, but the example of how an internal report was dealt with is evidence of a failure of leadership within CQC and a dysfunctional relationship between the executive and the board.

“There is evidence of a defensive, reactive and insular culture that resulted in behaviour that should never have happened.”

‘Depressing reading’

David Prior, CQC’s chairman, said: “CQC’s chief executive, David Behan, was absolutely right to commission an independent report into CQC’s handling of the registration and subsequent monitoring of UHMB – and absolutely right to publish it in full.

“The publication draws a line in the sand for us. What happened in the past was wholly unacceptable. The report confirms our view that at a senior level the organisation was dysfunctional. The board and the senior executive team have been radically changed.”

Commons health select committee chairman Stephen Dorrell said the report made “extremely depressing reading” that underlines past failings of the CQC.

But he told BBC Radio 4’s Today programme that the regulator was now on the right track following of a clear-out of the senior management.

“This is clearly a very sad tale of failure to respond when evidence was produced of service failure and then, having failed to react, covering up the fact that they’d failed to react – which is unacceptable behaviour anywhere in the public sector but in particular in a regulator,” he said.