Letter: Unheeded deaths warnings. Neglect. A care home owner with criminal convictions. Indefensible CQC.

Letter to House of Commons Health Committee 15 October 2016



To Health Committee, 15 October 2016


Dear Dr Wollaston and colleagues,

Unheeded deaths warnings. Neglect and a care home owner with criminal convictions. Indefensible CQC.

I write to submit additional evidence for the next CQC accountability hearing.

The CQC remains insufficiently accountable, insufficiently sighted on critical risks and sentinel events, and unfit to safeguard vulnerable service users. It needs to be replaced


Almost a year ago, Public Accounts Committee found that the CQC was still an ineffective regulator, that it had not adhered reliably to its own policy on safeguarding, that it did not handle data well or provide the public with adequate data about regulated services, and that it did not listen enough to service users and whistleblowers. Regarding CQC accountability, the committee found that despite previous criticism in 2012, the CQC’s framework for monitoring its own performance was still inadequate:

“….the Commission does not yet have the quantified performance measures, linked to explicit targets, that are needed to show whether it is satisfactorily performing its statutory duties…only 6 out of the 37 performance measures included in it have specific, quantified, targets”[1]

Also a year ago, The Bureau of Investigative Journalism and the Independent revealed that the CQC had not inspected 9 out of 23 care homes where coroners’ warning reports had been issued about deaths.[2] David Behan acknowledged that these failures were ‘indefensible’ and promised to make improvements, including analysis of coroners’ intelligence.


New analysis on coroners’ warnings about care homes

I have updated the work, and cross-checked coroners’ Reports to Prevent Future Deaths (PFDs) against CQC inspection records. There was no published evidence that CQC had inspected 18 out of 66 homes despite coroners’ warnings. Where CQC had inspected, its response was slow and erratic. I have summarised my findings in a paper that I have published here, with supporting data:


It shows that the CQC was sent 31 of the 66 care home PFDs, 11 of which were directly addressed to CQC as a named respondent. There was no published CQC response to 9 of the PFDs. In one of two cases where CQC was specifically criticised by the coroner, there was no published response by CQC. I have been unable to find any published analysis by CQC of coroners’ intelligence.


Ivy Atkin, Autumn Grange and CQC’s lack of learning

CQC’s ongoing failures have again been highlighted by the profoundly shocking death of 86 year old Ivy Atkin who died weighing 3 st 13 lb, only twenty days after CQC issued a favourable report on her care home, Autumn Grange.

CQC inspection report on Autumn Grange care home 2 November 2012:


Click to access 1-101618554_sherwood_rise_limited_1-126202251_autumn_grange_residential_home_20121102.pdf

This inspection report was published on the same day that CQC carried out an unannounced re-inspection of Autumn Grange as a result of a member of staff blowing the whistle only three days after starting work at the care home. In addition to the horrific neglect of Ivy Atkins, other residents at Autumn Grange also suffered severely and were found to have unexplained injuries. ITV news reported that other staff also came forward and alleged mistreatment, including assault. A ‘culture of neglect’ was described, thus raising a question of whether the dysfunction had been present for some time:


The coroner has now concluded that Ivy Atkin was unlawfully killed, and that CQC failed to inspect the care home effectively. [3]

The care home owner was jailed in February for corporate manslaughter. During the course of the recent inquest, the coroner expressed concern that he had three criminal convictions: 

“A coroner has questioned how a care home boss was able to run the business where pensioner Ivy Atkin lived before she died – even though he had three criminal convictions…

…The inquest heard on Thursday that home director Yousaf Khan was convicted of criminal damage in 1989, a public order offence for punching and kicking a person in a restaurant in 1998 and drink-driving in 2000.” [4]

Despite obvious and serious questions about CQC’s handling of the issues relating to Autumn Grange, the CQC told me that it had not undertaken any internal review of its actions, and implied that there was no need to do so because its processes are “better than ever”. This correspondence with CQC is attached. [5] The inspector responsible for the inspection 7 weeks before Ivy Atkin’s death maintained at the inquest that she had not “missed anything” and that care homes can go “downhill quickly”. In a discussion yesterday about Ivy Atkin’s death, a CQC Non Executive Director responded thus to a campaigner’s concerns that CQC is reactive and not sufficiently proactive: “Er, this was 4 years ago”.


I find this attitude by CQC deeply shocking, set against the cruel death that befell Ivy Atkin. There is much rhetoric from the Secretary of State that the CQC is a new organisation under his stewardship. However, even the previous CQC regime undertook an internal review after abuse at Winterbourne View was exposed. The severity of the failings at Autumn Grange was much greater than at Winterbourne View, yet the current CQC regime has not seen fit to properly hold itself to account.

The history of serial failure by the CQC to safely regulate care homes and provide the public with accurate information – highlighted 22 times by Private Eye since 2010 – is summarised in this comprehensive report by the campaigning charity Compassion In Care: http://www.compassionincare.com/node/229


CQC value for money

The Mazars report on Southern Health NHS Foundation has raised serious doubts about the accuracy of CQC’s so-called ‘intelligent monitoring’, which is a cornerstone of CQC’s purported ‘transformation’. Moreover, a £273,908 CQC inspection [6] of Southern Health in 2014 did not report on the hundreds of uninvestigated unexpected deaths, later identified by Mazars’ investigation.

After seven years of failure by CQC and frequent refusal to investigate key matters (CQC disclosed by FOI that it had undertaken only 6 Section 48 investigations since inception [7]) I contend that the CQC’s approach does not work, is not safe and is poor value for money.

The hundreds of millions spent every year on CQC – on a ‘transformation’ that is not actually evident – would surely be better spent on leaner, focused, and professionalised investigation services, such as that which revealed the grave care failings at Mid Staffordshire:


I note that the Healthcare Safety Investigation Branch (HSIB) has now been created to carry out healthcare investigations, but its currently slender funding results in inadequate capacity. It has an intended rate of only 30 investigations a year, and the Department of Health advised that this capacity may even reduce. [8]

CQC’s latest National Guardian for whistleblowing has extolled the virtues of cheerfulness: https://minhalexander.com/2016/10/10/hooray-henrietta/




However, CQC unfortunately gives the health and care workforce little cause to smile.

Yours sincerely,

Dr Minh Alexander


cc  Public Accounts Committee

Public Administration and Constitutional Affairs Committee

Keith Conradi Chief Investigator, HSIB



[1] Public Accounts Committee. CQC inquiry. December 2015


[2] Elderly people put at risk as watchdog fails to act on warnings of ‘fatally negligent’ care homes. Melanie Newman and Oliver Wright, The Independent, 2 September 2015


[3] Ivy Atkin death: ‘Unlawful killing’ over care resident death, BBC 13 October 2016  http://www.bbc.co.uk/news/uk-england-nottinghamshire-37649387

[4] Owner of the care home where Ivy Atkin stayed before her death had three criminal convictions, Jemma Page, Nottingham Post, 14 October 2016


[5] Correspondence February and March 2016 with CQC, about whether it had undertaken an internal review on its inspection activities at Autumn Grange


[6] FOI disclosure about the cost and details of a CQC inspection on Southern Health:


[7] FOI disclosure by CQC about the number of Section 48 inspections undertaken since CQC’s inception:


[8] FOI disclosure by the Department of Health about HSIB:




4 thoughts on “Letter: Unheeded deaths warnings. Neglect. A care home owner with criminal convictions. Indefensible CQC.

  1. I need to say that I enjoy reading your posts – not for the content of the most alarming and/or morally corrupt behaviours by those in positions of authority, but for your attempts to hold such creatures to account and try, against all of the odds, to protect those innocents who are frail, vulnerable and therefore prone to abuse.

    You will obviously know as well as I, if not much better, that the only guaranteed way to be heard is to be in a powerful position. But, it appears that, the only people who are in a powerful position are, as your posts demonstrate, either ‘useful idiots’ or ocean-going, ruthless narcissists.

    I have always believed, and tried to practice, that it is part of one’s democratic duty to engage with society’s institutions, understand how they work in order to learn enough to ask relevant questions and judge the worth of the answers. Thus, one can support or censure society’s institutions and prevent them from becoming self-serving, self-referencing, corrupt institutions.

    For what it’s worth, I now believe that the Government reflects the general population – the innocent and vulnerable are of little use economically and can be culled, probably after being scapegoated as being NHS bed-blockers, etc. This, in turn, merely reflects the nation’s moral compass which, if it is around at all, is probably broken and rusty.

    Nevertheless, as your mission shows, there are some good souls beavering away, so there is some hope. I believe the Jewish culture has a saying that, as long as there is one good man in the world, all is not lost.

    Please accept this as a note of my respect for you, particularly in having to read drivel from the failed CQC’s inspector who obviously didn’t inspect and whose suppurating excuses went unchallenged – the cover-up invariably being worse than the original cock-up.

    I thank you and shall look forward to your further reports albeit with clenched fists and gritted teeth.


  2. Thank you very much zrpradyer. It is indeed horrible how the indifference to some lives has become so obvious. A detail that really got me was there was no hot water.

    I hear from someone who regularly investigates care home failings that this isn’t unique. It’s chilling to think that some people set out to make a profit from other human beings in this manner, and very sad that as a society we tolerate it.

    Liked by 1 person

  3. Thank you for responding.
    I imagine you could be referring to Eileen Chubb – an exemplary campaigner who is thus largely ignored by those who should be grovelling their appreciation and gratitude at her feet.
    We live in an upside la-la world!
    I wish you well.


  4. Yes. Eileen Chubb is a treasure and has helped countless people.

    Another reader has left the following comment under the earlier piece “Do complaints matter to CQC” https://minhalexander.com/2016/10/02/do-complaints-matter-to-cqc/

    It is another story of care home neglect, weight loss and poor responses by the powers that be. I wonder but for luck and the efforts of families, how many people would suffer Ivy Atkin’s fate:

    “CQC told me that they had investigated my complaint (about the appalling conditions my grandmother was found to be in on multiple occasions at her former care home) When I pressed for details of this “investigation”, it was admitted that they had not visited the care home and that instead they’d relied on a report from the safeguarding team of the local authority – who had taken almost 2 weeks to respond to the alert, and then notified the care home of their visit – no surprises that conditions at the care home were considered acceptable.

    We’ve since seen FOI material where the safeguarding team concluded that the reason we’d complained is because we were annoyed that my grandmother had been given notice to leave! They learned this from the social worker.

    In fact we spent the next few months insisting that she moved to another care home, against huge opposition from social services and the care home – even though the manager issued a notice to leave whenever we perisisted (civilly) with our questions.
    Thank God (!) she broke her hip – once she was in hospital, she began to eat and regain weight and her mental and emotional state improved hugely.
    We then had confirmation that she wasn’t dying of cancer – the manager of the care home had told us this lie several months previously.
    I can only assume this was to distract us from continuing to ask for answers to our questions, and to explain the drastic weight loss.

    She is now happily settled at another care home, has regained weight and is noticeably happier…however her experiences at her former care home have taken their toll and have shortened her life, of that I am certain.

    Long story but there has been collusion between the care home/social services and a financial deputy who was involved in order that a retrospective charge of approx £10,000 could be made – no explanation of this charge or why none of us were notified, despite being financial agents for my grandmother. Getting rid of a financial deputy is extremely difficult – the court of protection are loath to admit that she should never have been appointed in the first place, that the capacity assessment was falsified and that my grandmother’s former arrangements have been swept aside and her wishes completely ignored. I would advise anyone not to wait until it’s too late: sort out a POA before it becomes necessary as once the court of protection become involved, it really is a case of the State taking over completely.

    NHS England are just as corrupt – they’ve attempted to block our complaint about the GP (who falsified a COP3 form and also diagnosed my grandmother with terminal cancer, without informing her family or sending her for tests)
    They said that my grandmother lacked capacity to consent to her family making a complaint on her behalf – despite the fact we had her written consent, witnessed by a grade G nurse.
    They were more interested in shutting us down, than in what had actually happened to my grandmother and the GP’s actions.

    I’ve had to persist for 3 months and it is only the intervention of her current GP that has forced them to instigate an investigation
    I’ve received an abject apology from a “director” who says that she has spoken to the manager and is now reassured that she has learnt from this and that it will not happen again – the question is, how many times has it happened previously, but because the complainant was perhaps not as persistent (bloody minded!) as I, they accepted NHS’s refusal to investigate.

    Following NHS’s England’s logic, a person who may lack capacity has absolutely no way of making a complaint about their treatment – unless they have given POA to someone. It is just madness

    As a family we’ve never had any involvement with social services – this has opened our eyes and made us realise that it’s all about profit, not what is best for the person that is paying for their own care.

    Thanks for listening”


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