CQC Deaths Review: All fur coat….

By Dr Minh Alexander, NHS whistlerblower and former consultant psychiatrist, first published 13 August 2016

After the abject failures by CQC, DH and other oversight bodies were revealed by the Mazars [1] report on failure to investigate hundreds of unexpected patient deaths by Southern Health, Jeremy Hunt predictably asked CQC to review the way the NHS handles deaths. [2]

What better way of keeping it in the family, whilst fobbing off the public with some superficially reassuring headlines.

Never mind that CQC has long been implicated as an essential part of what Professor Brian Jarman called the NHS Denial Machine. [3]

CQC itself is only reviewing what trusts do. Purportedly, there is other work by the DH that “may” result in changes to regulatory process. There is passing reference to this in CQC’s review blurb, but I am not aware that any details of this work have been published. [4]

After I posted criticism of CQC and the limited remit of the deaths review in the twitter hashtag #CQCDeathsReview, I was approached via twitter by a CQC official who assured me that the enforcement of good practice would be reviewed as well. This person invited my contribution and offered me a meeting with the deaths review team. When I asked for more information, a telephone call was offered. When I asked for written information and the actual terms of reference of any review of regulatory performance, the communication petered out. This is unfortunate as the deadline for submission of evidence is this Sunday, 14 August.

No doubt it was a well-meaning approach, by someone who had not yet discovered that the CQC has developed a habit of writing frosty letters to me via its Director of Legal Services.

However, there is a startling contrast between the frenetic publicisation of CQC’s review of trusts’ performance in handling deaths, compared to the opacity and silence over the purported (and more important) review of oversight processes. The message is one of double standards: “No stakeholder scrutiny please, we’re too important”.

This unwillingness by the DH, and its arm lengths bodies such as CQC, to properly account for their failures to protect patients is typical of a longstanding pattern of behaviour. Major reports which criticised the DH’s role in creating a culture of fear and compliance, instead of a genuine focus on quality and patient safety, were suppressed by the DH in 2008 and only released in 2010 by FOI. [5] [6] [7]

It is most unlikely that the whole truth will be allowed to emerge about the NHS’ continued mishandling and subterfuges about patient deaths.

A review of CQC inspection reports on English mental health trusts raises serious questions of systematic evasiveness by CQC about patient deaths. [8]

Only one of the new-look CQC inspection reports published so far on mental health trusts gave the numbers of deaths of patients under the Mental Health Act. The rest of the reports carefully side-stepped this critical data, even in instances where CQC admitted that some trusts were noted to be at elevated risk of deaths and or suicides under the Mental Health Act. At Mersey Care, a CQC report of October 2015 claimed that although the trust had an elevated risk in terms of the number of suicides under the Mental Health Act, the figures were not given because the numbers of deaths were low and could lead to identification. [9] Yet there are plenty of occasions when CQC reports have referred to very small numbers of other types of incidents, for example: a serious injury sustained by a detained Southern Health patient after climbing onto a roof that was too easily accessed. Perhaps the real issue is government reluctance to reveal the scale of Article 2 Right to Life legal claims to which it is potentially exposed, with liability being most obvious in the deaths of patients detained by the State.

The Mazars report did not spare CQC’s blushes on Mental Health Act deaths. Mazars’ investigation found that Southern Health reported 27 deaths of patients under the Mental Health Act to CQC. However, CQC managed to mislay 9 of these, and told Mazars that there had only been 18 deaths of Southern Health patients under the Mental Health Act.

There is generally arbitrary variation of the way in which deaths data was presented from one CQC report to another. The time periods sampled varied for no given reason. CQC showed Goldfish grade organisational memory in that the time periods sampled were short (mostly around a year or so, distributed variably in time prior to the inspection visits), and there was very little evidence of benchmarking against past deaths. Consequently, there was almost no longitudinal perspective on the degree to which organisations were repeating the same failings. CQC sometimes gave a breakdown of the types of deaths, but sometimes not. Suicide is sometimes not mentioned at all, which is rather surreal when a regulator is reporting on mental health service safety.

The July 2015 CQC inspection report on Kent and Medway, from an inspection chaired by no less than Paul Lelliot CQC’s Deputy Chief Inspector and CQC lead for mental health, did not mention deaths at all. [10] This is rather extraordinary as Kent and Medway has received at least 13 coroner’s warning Reports to Prevent Future Deaths, including 4 reports in 2014.

Similarly, the numbers of deaths were not reported at all by the CQC inspection report on Nottinghamshire Healthcare, of July 2014. [11] Instead, there was only a brief claim that the number of Nottinghamshire Healthcare’s deaths was in the expected range. Paul Lelliot also chaired this inspection.

At the very troubled and “Inadequate” Norfolk and Suffolk, which has seen very harsh staffing cuts in recent years, CQC’s latest inspection report of February 2015 [12] also contrived not to give the numbers of any deaths whatsoever, despite the fact that the local media has been filled with frequent reports of campaigners’ concerns about increased numbers of deaths and trust inquests. In this context, a question arises of whether this failure by CQC to report the number of Norfolk and Suffolk deaths was a politicised decision.

There were other CQC reports that did not give the numbers of deaths, and some that gave conflicting numbers of deaths, with no attempt by CQC to reconcile the conflicts.

Importantly, CQC only described reported deaths. There was no evidence that CQC checked on whether reporting was accurate and reliable. In some trusts, CQC stated that no deaths had been reported at all, but gave no indication that inspectors had dug deeper to verify the number of deaths. I have told CQC many times that not all deaths and serious incidents are reported. Mazars also gave ample evidence that not all deaths are reported: there were a total of 10,306 deaths at Southern Health between 2011 to 2015, but only 195 were reported as serious incidents requiring investigation (SIRIs). Some of the trusts with zero reported deaths were rated “Good” by CQC. CQC did not describe any attempts to cross check directly with coroners. There is evidence that CQC relied on some trusts to tell them how many coroners’ warning reports had been received: The trust told us about four subsequent coroners’ rulings (regulation 28 rulings)”. In this particular instance, this information was incorrect and there had been two additional coroners’ warning reports.

Bizarrely, the November 2015 CQC inspection report on Lancashire Care NHS Foundation restricted itself to looking at Coroners’ warning reports from only 6 months in 2013:

Every six months, the Ministry of Justice publishes a summary of recommendations that had been made by coroners with the intention of learning lessons from the cause of death to help prevent deaths. There were no concerns raised regarding the trust in the most recent report (April 2013 – September 2013).” [13]

In fact, Lancashire Care had 5 coroners’ warning Reports to Prevent Future Deaths from December 2013 up to the time of CQC’s report. A very serious question arises about why CQC chose to ignore this evidence and to exclude it from its inspection report.

CQC performed the same worrying manoeuvre in its February 2015 inspection report of the extremely troubled Norfolk and Suffolk. The CQC report claimed that

“In the latest report covering the period from October 2012 to March 2013 there were no concerns regarding the trust raised by the coroner.”

Firstly, this was wrong as there was a coroner’s warning report issued on

28 March 2013 on the death of a patient detained under the Mental Health Act. Moreover, there were another 6 coroners’ warning reports after that, up to the time of CQC’s inspection report. In total, Norfolk and Suffolk have had at least 22 coroner’s warning reports, which is one of the highest if not the highest numbers of coroners’ warning reports nationally.

The same dodgy dance steps were followed at Avon and Wiltshire Partnership, when the CQC July 2015 inspection report claimed:

“In the latest report covering the period from October 2012 to March 2013 one concern regarding the trust was raised relating to the death of a patient at Fromeside” [14]

In fact, from September 2013 to the time of CQC’s inspection report, there were at least 8 further coroners’ warning reports. Avon and Wiltshire Partnership has had at least 17 coroners’ warning reports in total, and some have described the most serious failures of care. These included the highly publicised case of a 2014 suicide-infanticide in which the trust was criticised by the coroner in October 2015 for not making adequate contingency plans for a very high risk pregnancy, in a patient with known psychotic illness. [15] [16]

At Greater Manchester West, CQC’s inspection report of June 2016 [17] mentioned only one coroner’s warning report in January 2016, when in fact between September 2013 and December 2015, there were 8 other warning reports issued.

At Devon Partnership, CQC’s inspection report of January 2016 [18] did not mention coroners’ warning reports at all, despite the fact that the trust has had at least 19 warning reports, with 4 issued between July 2014 and October 2015.

CQC’s January 2016 inspection report of SLAM [19] was equally silent on coroners’ warning reports, when there had been a total of at least 19 warning reports, with 8 issued between August 2013 and July 2015.

At troubled Sussex Partnership, CQC’s inspection report of May 2015 [20] also did not mention coroners’ warning reports at all, despite the fact that there had been a total of 11 reports up to the time of CQC’s inspection report, with 8 reports issued between August 2013 and April 2015. This inspection was chaired by Paul Lelliot.

There were other examples of CQC selective omission of coroner’s warning reports from inspection reports.

The only CQC report that gave detailed data on deaths and their handling was the post Mazars inspection report on Southern Health. The superficial Pre-Mazars inspection report on Southern Health of February 2015 mentioned ‘death(s)’ only six times. [21] The post-Mazars inspection report of April 2016 mentioned ‘death(s)’ 94 times. [22] Ironically, CQC states in this latest report that the trust should “give a more transparent breakdown of deaths” in its annual report. It is a pity that CQC does not devote the same thoroughness to trusts where there has been less publicity about deaths, and does not follow its own advice about transparency regarding the pattern of deaths.

The overall superficiality, passivity, frank inaccuracy and lack of standardisation by CQC means that the deaths data presented by CQC reports is not robust, is sometimes seriously misleading, and that it is difficult to track the performance of individual trusts or to compare trusts. Politically however, the moveable measurement goal posts keep CQC’s options open, and make it easier to stretch a rating to fit when required. Jeremy Hunt’s vision of a “single version of the truth” by an authoritative and trusted regulator is yet more tarnished tinsel.

They really should all toddle off to M&S for some items of intimate apparel.


[1] Mazars December 2015 report on Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015


[2] Written statement by Jeremy Hunt Secretary of State 17 December 2015 on Southern Health


[3] Labour’s ‘denial machine’ over hospital death rates. Telegraph 14 July 2013


[4] CQC scoping paper for deaths review http://www.cqc.org.uk/sites/default/files/20160624%20Investigating_deaths_across_mental_health_acute_and_community_setting_Scoping_Paper.pdf

[5] When managers rule, patients may suffer and they’re the ones that matter. Prof Brian Jarman BMJ Editorial 19 December 2012 BMJ 2012;345:e8239


[6] Institute of Health Improvement 2008 report, Achieving the Vision of Excellence in Quality: Recommendations for the English NHS System of Quality Improvement


[7] Joint Commission International 2008 report, Quality Oversight in England – Findings, Observations and Recommendations for a New Model


[8] The main data collated on data about deaths in CQC mental health trust inspection reports can be found uploaded here:


[9] http://www.cqc.org.uk/sites/default/files/new_reports/AAAD5292.pdf

[10] https://www.cqc.org.uk/sites/default/files/new_reports/AAAC9675.pdf

[11] http://www.cqc.org.uk/sites/default/files/new_reports/AAAA1862.pdf

[12] http://www.cqc.org.uk/sites/default/files/new_reports/AAAA3470.pdf

[13] http://www.cqc.org.uk/sites/default/files/new_reports/AAAD1977.pdf

[14] http://www.cqc.org.uk/sites/default/files/new_reports/AAAC0116.pdf

[15] Bristol mother Charlotte Bevan and missing baby CCTV issued. BBC 3 December 2014 http://www.bbc.co.uk/news/uk-england-bristol-30316699

[16] Coroner’s Report to Prevent Future Death in the case of Charlotte Bevan, 27 October 2015 https://www.judiciary.gov.uk/publications/charlotte-bevan/

[17] http://www.cqc.org.uk/sites/default/files/new_reports/AAAF1696.pdf

[18] http://www.cqc.org.uk/sites/default/files/new_reports/AAAD7774.pdf

[19] http://www.cqc.org.uk/sites/default/files/new_reports/AAAE6494.pdf

[20] https://www.cqc.org.uk/sites/default/files/new_reports/AAAC1746.pdf

[21] http://www.cqc.org.uk/sites/default/files/new_reports/AAAB9266.pdf

[22] http://www.cqc.org.uk/sites/default/files/new_reports/AAAF4191.pdf


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