Letter 9 September 2016 to David Behan CQC Chief Executive on CQC under-reporting of coroners’ mental health deaths warnings

From: Minh Alexander <minhalexander@aol.com>

Subject: CQC’s reporting of coroners’ Reports to Prevent Future Deaths

Date: 9 September 2016 at 09:01:46 BST

To: “Behan, David” <David.Behan@cqc.org.uk>, Health Committee <healthcom@parliament.uk>, sarah.wollaston.mp@parliament.uk, philippa.whitford.mp@parliament.uk, paula.sherriff.mp@parliament.uk, julie.cooper.mp@parliament.uk, james.davies.mp@parliament.uk, andrea.jenkyns.mp@parliament.uk, andrew.percy.mp@parliament.uk, maggie.throup.mp@parliament.uk, bradshawb@parliament.uk, meghilliermp@parliament.uk, Bernard Jenkin <bernard.jenkin.mp@parliament.uk>, deborahcoles@inquest.org.uk, HSIB <info@hsib.org.uk>, admin@avma.org.uk


To David Behan Chief Executive Care Quality Commission, 9 September 2016

Dear Mr Behan,

CQC’s reporting of coroners’ Reports to Prevent Future Deaths

I write to inform you of an irregularity regarding information about coroners’ Reports to Prevention Future Deaths.

In CQC’s annual Mental Health Act monitoring report for the period 2014/2015, it is reported that:

“Between December 2014 and June 2015, we received three ‘Prevention of future death reports’ concerning patients who were receiving mental health services at the time of their death; one report related to a detained patient.” (Page 27)

I have found by searching information uploaded by the Chief Coroners’ office, that there were at least 92 Reports to Prevent Future Deaths on mental health service patients in the period 2014/2015.

Additionally, six of the 92 reports related to detained patients.

Five of the 92 reports, which related to informal patients, appeared to have been copied to CQC by coroners. One of the five was sent to you personally. I provide links below to all five original reports.

I would be grateful to understand why CQC did not include all relevant data in its 2014/2015 report, particularly as it advised in its 2013/2014 report that:

“Coroners Society: In 2014 we developed a memorandum of understanding with the Coroners Society. We now receive information from individual coroners’ reports about any deaths in health and care settings and how these could be prevented in future.” (Page 33)

Yours sincerely,

Dr Minh Alexander

cc Health Committee

Chairs of Public Accounts and Public Administration and Constitutional Affairs




Keith Conradi Chief Investigator HSIB


Five coroners’ Reports to Prevent Future Deaths that were apparently copied to CQC by coroners in 2014/2015:






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