CQC, coroners’ warnings & the neglect of older people in hospital

By Dr Minh Alexander, NHS whistleblower and former consultant psychiatrist, 2 October 2017

On 29 September 2017 Professor Ted Baker the new CQC Chief Inspector reportedly made highly politicised comments stating that the NHS was not fit for the 21st Century. He said that the NHS had failed under Labour’s government to adapt to an ageing society with more complex needs. 1

Unsurprisingly he did not refer to the current Conservative government’s policy of aggressively defunding and destabilising the NHS over the last seven years.

Unhelpfully, Baker added to the corporate hectoring against beleaguered managers doing their best in increasingly intolerable conditions with this admonition:

Prof Ted Baker said it was “not acceptable” to keep “piling patients into corridors” as he urged hospital leaders to act swiftly to guard the safety of those in their care.

In his first interview as chief inspector, he said too many hospitals had normalised “wholly unsatisfactory” arrangements which endangered patients, as well as denying basic privacy and dignity.

Prof Baker has written to all hospital chief executives, calling for immediate action to improve safety in A&E, amid fears the NHS will struggle to cope with overcrowding this winter.

This follows surreal revelations that NHS England senior managers made NHS chief executives chant ‘We can do this’ in relation to forthcoming winter A&E performance. 2

The fact is, the economically unviable, frail older people, the seriously mentally ill and learning disabled and the severely physically disabled have rarely been treated by politicians with the care and respect that they deserve. There aren’t enough votes in it.

The list of NHS scandals involving the care of older people is long.

Beech House 3

I whistle blew on some neglected dementia back wards, early in my career but was intimidated and ignored by the local psychogeriatric consultants. Matters might have been worse for me if I had not been protected by other senior staff. A few years later, serious physical and mental abuse of the elders was uncovered and reported in the Beech House Inquiry by Camden and Islington.

Abuse at Beech House:

Screen Shot 2017-10-02 at 14.15.19

Shipman murders 4

The infamous and numerous murders by Harold Shipman flew under the radar for years, partly as his victims were mostly elderly.


Gosport Memorial Hospital deaths 5

The controversial deaths are now subject to yet another inquiry after years of unsatisfactory investigations.


North Lakelands scandal 6

This related to the mistreatment of psychogeriatric patients and was reported by CHI, one of CQC’s more effective predecessors:

“A culture developed within the Trust that allowed ‘unprofessional, countertherapeutic and degrading – even cruel – practices’ to take place. These practices went unchecked and were even condoned or excused when brought to the attention of the Trust.” 6

 CHI is deeply disturbed by the consultant’s lack of awareness and passive acceptance of being treated like a visitor on the ward where the abuse occurred.6


Liverpool care pathway 7

The discredited Liverpool death pathway was a significant stain on the NHS’ reputation, with reports abroad such as:

“UK to scrap notorious Liverpool care pathway, criticized as gateway to euthanasia” 8

And then there are the common or garden intermittent headlines that recur periodically about the neglect of older people in hospitals. For example, failures to ensure nutrition and help with other basic daily functions. 9

Politicians know full well that there is serious unmet need, but typically resist funding decent care for the most vulnerable. The real scale of harm is hidden by ageist assumptions, the fact that older people are expected to die, and that fewer questions are asked when they do. Cases that should be reported to coroners are not. I give an example below.

Moreover, the current government continues to delay the establishment of medical examiners, despite having accepted that they are needed. 10

It has also made a religion out of prizing profit above people, actively persecuting the vulnerable to the extent that it has attracted United Nations censure for breaching Human Rights. 11



See the Disability News Service website for in depth coverage of the UK government’s violations of the rights of disabled people:





This bell tolling the death of decency has been ringing for years now. CQC with its birds-eye view of both health and social services knows exactly what has been happening. Baker has worked for the CQC since 2014 11 so had three years to say something.

Baker’s intervention this weekend was a perfect sample from the Hunt public relations play book: Tough-new-shiny-independent-regulation…. by the Health Secretary who cares. The truth however is the CQC is just another arm of government, dressed up as a regulator but moving to invisible strings.


Coroners’ warnings

Coroners regularly issue Section 28 warning reports on ‘Action to Prevent Future Deaths’ (PFDs) about the poor care of older people in NHS hospitals, which since 2014 have been automatically copied to the CQC based on a memorandum of understanding with the Coroners’ Society.

Based on data published by the Chief Coroner, there is roughly at least one Section 28 report issued every week that relates to harm or risk associated with the care of older people in NHS hospitals.

Screen Shot 2017-10-02 at 17.05.41.png

Section 28 reports on the inpatient care of older people have accounted for at least 19.7% (195 of 987) of all published Section 28 reports relating to the NHS in the last four years.

This is a spreadsheet with reference details of the 195 cases:


There were 101 women and 94 men.

171 deaths related to the English NHS and 24 deaths related to the Welsh NHS.

The figure of 195 is conservative because the data in Section 28 reports is not standardised, and age is not always stated. I did not include some reports that probably related to older people because there was insufficient indication of age. I have also used an age threshold of 70 and not 65 years. 12

Eleven of the 195 (5.6%) cases attracted a formal finding of neglect. Neglect was described or implied in a number of other cases where a formal finding of neglect was not reported. 13

5.6% is a slightly higher proportion than the proportion of neglect cases amongst all published Section 28 reports relating to NHS care in the same period –  49 cases of neglect out of a total 987 (4.9%). 14

This set in the context that 24 of a total of 60 (40%) published Section 28 reports from all sectors with a finding of a neglect related to people over the age of 65.

It is also important to stress that coroners’ Section 28 reports represent only the tip of the safety iceberg.

Of the 195 NHS cases of harm or risk to older people receiving NHS hospital care, some of the coroners’ concerns related to factors that applied to all patients regardless of age.

However, a number raise questions about low expectations, ageist attitudes and possible cover ups:


  1. The coroner for South Manchester felt that Elsie Mallalieu was “written off”:


  1. There were two cases featuring the Liverpool care pathway, the deaths of Alva Jullien and Agnes Hannan:



  1. The coroner for Brighton and Hove considered that Herta Woods had been “abandoned” in hospital:


  1. The same coroner reported that Evelyn Kennedy had been so severely neglected that one ward at Brighton and Sussex raised a Safeguarding about another ward’s practice:


  1. The same coroner noted that Jack Molyneux was so neglected by Brighton and Sussex that a care home immediately made a Safeguarding referral when he was discharged to their care:


  1. The coroner noted that Alwyn Head’s MRSA related death at Medway occurred in the context of poor care, including a 12 day period in which there was no evidence that a wound was checked and in which effectively “meaningless” nursing entries were made.


  1. Susanna Geraty was a fit 75 year old who died after staff failed to give her enough fluids after surgery for a fracture, and she sustained acute renal failure in consequence:


  1. Mrs Care died with a large unexplained bruise:


  1. Doreen England died of a grade 4 pressure sore which developed in hospital


  1. Devindar Seth suffered opiate poisoning under Barts’ care and this was not detected by staff but pointed out by the family.


  1. In the death of Barbara Cooke with contributory neglect from serious care failures, the coroner for the Isle of Wight noted that the doctors treating her completed a death certificate instead of reporting the death. The coroner was only alerted to the death by chance:


  1. In the death of Leslie Pates at Tameside hospital, the coroner was concerned that the consultant had submitted a report stating that Mr Pates was discharged from hospital without a temperature and a clean pressure sore, when the discharge quickly failed and another doctor from the trust gave the cause of death as ‘sepsis’:


  1. 91 year old William Beckwith died after being discharged home by the Royal Chesterfield in the small hours of the morning with an undetected cervical fracture. Eight months after his death, the coroner noted:

The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning.


Widespread unsafe discharges of older people, resulting in emergency re-admissions were flagged by a 2015 Healthwatch England briefing:



No doubt the current bullying of trusts by NHS England and CQC to pull their socks up on A&E performance targets will do little to stem unsafe discharges.

Trusts are not expected to answer back or to highlight glaring unmet need. Indeed, the centre’s behaviour is more likely to result in cover ups.

Several coroners’ Section 28 reports referred to very unsatisfactory internal investigations into the deaths of older people. For example:

“…investigative procedures were demonstrably inadequate”

“The SI report failed to consider or acknowledge lack of fluids as a cause of her acute renal failure despite expert evidence that it was the only credible cause” 

“The report contained serious factual inaccuracies”

Staffing issues were explicitly flagged by coroners in 19 of the 195 cases of care failures involving older people, whether in terms of numbers, skill mix or lack of specialist staff. For example, a lack of physiotherapy at weekends was flagged as a risk to some frail older patients.

In the death of Leslie Murray under St George’s care, the coroner noted that he was assessed as needing 1:1 care but suffered a fall which led to his death because this care was not put in place:

Screen Shot 2017-10-02 at 15.32.45

Of great concern, the coroner also noted that this situation occurred ‘frequently’:

Screen Shot 2017-10-02 at 12.38.30


Preventing falls requires safe levels of nursing staffing, sufficient to provide attentive and responsive care for frail older people with sensorimotor handicaps.

Of recurring clinical errors flagged by coroners, failures of falls prevention were very prominent. Thirty five of the 195 cases featured poor falls management, with either inpatient falls (the majority) or falls related to unsafe discharges.

This is unsurprising given repeated reports from nursing staff that they do not have enough time to give all the care that patients need. 15

The latest Royal College of Nursing report based on 30,000 survey responses about nurses’ last shifts, advised that over half of respondents said that care had been compromised on their last shift due to understaffing:


A 2012 Royal College of Nursing survey of nurses revealed these gaps in older people’s care due to inadequate staffing, which includes the vital task of preventing falls:

Screen Shot 2017-10-02 at 14.54.34


When there is serious, systemic and recurrent failure to meet foreseeable need this is classed as institutional abuse. To quote the DH’s own words:


Neglect and poor professional practice also need to be taken into account. This may take the form of isolated incidents of poor or unsatisfactory professional practice, at one end of the spectrum, through to pervasive ill treatment or gross misconduct at the other. Repeated instances of poor care may be an indication of more serious problems and this is sometimes referred to as institutional abuse.

Department of Health 2000



But I suspect that many of the 195 cases of poor care of older people flagged by coroners were never even formally referred as Safeguarding cases to the relevant local authorities. It would be useful to clarify this.

But who would one refer – the service providers or the government that is ultimately responsible through its policies?

I have now written to the newly created Healthcare Safety Investigation Branch, to submit the coroners’ evidence on poor care of the elderly in general, and to raise the specific issue of preventable falls and also the NHS’ compliance with Safeguarding procedures where the harm in question was caused by the NHS itself.



CQC an ongoing concern


4 years of published coroners’ Section 28 reports in England and Wales


Covering up cover ups: CQC revisionism




1 NHS is not fit for the 21st century hospital Chief Inspector warns, Laura Donnelly, Telegraph 29 September 2017


2 ‘Humiliated’ NHS hospital bosses forced to chant ‘we can do this’ over A&E targets, Jon Sharman, Independent,  26 September 2017



Report of the internal Inquiry Relating to the Mistreatment of Patients Residing at Beech House, St Pancras Hospital During the Period March 1993 – 1996, Camden and Islington NHS Foundation Trust 1999

Elderly patients punched and abused, BBC January 1999


4 The Shipman inquiry reports 2002-2005:


5 Portsmouth Healthcare NHS Trust at Gosport War Memorial Hospital, CHI 2002


Gosport hospital deaths inquiry looks into 800 certificates signed by Dr Opiate, Lois Rogers,  Times, 20 August 2017


6 The North Lakeland NHS Trust, CHI report to Secretary of State for Health 2000


7 DH review of Liverpool Care Pathway 2013


8 UK to scrap notorious Liverpool care pathway, criticized as gateway to euthanasia


9 Hospitals discriminate against the elderly, BBC 2 November 1998


Malnutrition in the community and hospital, Patients Association 2011


Half of hospitals failing to feed elderly patients properly, Guardian 8 October 2011


Hospitals show ‘shocking’ lack of care discharging vulnerable patients, James Meikle, Guardian 21 July 2015


Healthwatch England special inquiry: Older People briefing 2015


10 Medical Examiner delay. Statement by Royal College of Pathologists March 2017


11 Government accused of breaching UN convention in its treatment of disabled people, May Bulman, Independent 20August 2017


11 CQC information about Ted Baker


12 There is no defined age threshold for services older people. Some services operate a threshold of 65 years but others also assess functional level and frailty. The definition of ‘adults of working age’ has also changed with government policy on retirement age. I have used a threshold of 70 years to be more certain of identifying patients who are clearly older people’s services users.


13 The eleven cases with findings of neglect, in the NHS inpatient care of older people:












14 This is the list of 60 Section 28 reports with formal findings of neglect, published up to 31 July 2017:


This is a prior analysis which found a total of 987 Section 28 reports relating to the NHS, published up to 31 July 2017:


15 NHS staff shortages ‘mean patients dying alone’ in hospitals, Nick Triggle, BBC 29 September 2017


6 thoughts on “CQC, coroners’ warnings & the neglect of older people in hospital

  1. Great workWill study closelyAs a march 2013 coroner report and 2017 showed same worse failings i am currently chasing cqc nhsi ccg hwatch nhse all with a role in failing in Lewisham and rectifying now  Cqc gave me a long point by point justification for having little effect..want to read it?LrSent from mngy Samsung Galaxy snmartphone.

    Liked by 1 person

  2. I did see Prof. Baker’s ticking off regarding A & E overcrowding and the placement of patients in corridors. From what I can gather, A & E don’t move patients into corridors because they have a warped sense of storage but because between a third to a half of all hospital beds have been removed and, hence there is nowhere else for them to go.
    There seems to be structural problems between the NHS and social care as provided by local councils, hence ‘bed-blocking’ plus the shambles successive governments have made regarding GP services which are so lacking in some parts of the country that patients are forced to go to A & E.
    Then we have A & E choked up with drunks and druggies, the former a consequence of encouraging social drinking i.e. a healthy tax revenue.
    I could rattle on indefinitely but what I am trying to say is that, it is diversionary to ‘blame’ a perceived failing onto what is a struggling victim of their own success i.e. A & E. And to use such diversionary statements gives an insight as to the direction that the CQC is going.
    Of course, everything in this world is arranged in hierarchies of power. As you rightly say, those who are too ill, frail or vulnerable will be crushed under the weight of the creatures above them. Yet, we all carry the seeds of our own destruction, and those who do not care to rise above such primitive survivalist concepts will one day receive their consequences.
    One final thought, on learning of some of the horrors that the old and the vulnerable suffer, I suggest that they would have longed for the ministry of the prolific serial killer, Harold Shipman, instead of the treatment they did receive. At least he killed quickly.
    Thank you, Dr. A.

    Liked by 1 person

    1. I & sisters thankfully managed to look after Mum at home after hospital( what a struggle to get her released and it was only after referring to the HCP phone call to us”she may be released later today” that we pushed for release. Lots of questions incl financial ones asked of Mum. Tired but relieved and I realize its not always an option for all. Maybe sensitive questions must have a legal input from family.

      Liked by 1 person

      1. Good for you.
        I looked after my mum – multiple issues plus eventual dementia. But, as you know, most of the care evolves around patience and respect for the suffering patient
        Blessings to you and your sisters. Hope you feel proud knowing what a wonderful service you provided for your mum.
        Zara xxxxxx


    2. My husband died immediately following an injection of morphine despite multiple warnings of morphine-intolerance. We were left alone with him. No-one came to check on him or formally pronounce him dead. Upon leaving resuscitation room a nurse told us that we were not to go anywhere as a police officer was coming to conduct formal ID. How did this nurse know he was dead? There was no autopsy. We were not told of morphine injection until months later and then inadvertantly. Chief exec refuses to disclose name of doctor who administered injection. Details of morphine removed from medical records. CQC useless. GMC useless. Formal complaints procedures unfit for purpose. Am staggered by extent and volume of lies mostly from high-status Trust figures. Want to know more?

      Liked by 1 person

      1. Dear Barbara,
        Please accept my condolences for the death of your husband. And please be assured I share your deep anger. They say, quite accurately, that the cover-up is worse than the original cock-up and that is true of all unnecessary deaths.
        I wish that I had words of comfort to offer, but I don’t. I have been involved in investigating various aspects of medicine, both personally and as a system of thought and a profession, for many decades. As a corollary, I have also become involved with many campaigns. In fact, today I was with the Chennai 6 campaign who petitioned the P.M. to try and get our government to put more effort into freeing innocent ex-servicemen from an Indian goal where they have been imprisoned for more than four years.
        Most of my time in recent decades involves deaths in custody. There seems to be an established system for dealing with innocents who are killed by the state. Invariably the victim is blamed and their relatives who ask questions treated as pests.
        As a routine, all investigations progress at a glacial rate, vital papers are not presented, anyone who queries evidence is accused of something unsavoury, everything becomes politicised. And once that happens, you not only have the institution to deal with but half the population.
        Medicine, in my view and experience, is the most diabolical of all our institutions from which to try and seek justice (or even health!). Any criticism is spun by P.R. and propaganda experts as an attack on a life-saving national treasure. As with all institutions, those who work within the system and control it, have the power. In our instance, patients are relatively powerless – they come and go and don’t understand the politics or the dynamics.
        The only suggestion I can offer is if you can try and find support from others with similar experiences. Action Against Medical Accidents used to have a good reputation, but I don’t know how they are regarded now. I only mention them and similar as a possible source of support.
        You might also like to contact Julie Bailey who founded Cure the NHS after her mother and others were starved and dehydrated to death at the Mid Staffs Hospital. Just to add to her grief, when she began campaigning, she was run out of town and her business was ruined by those who will defend the NHS at all costs even when it has have been found guilty of abominations.
        I am afraid I have no respect whatsoever for the GMC, or other vested interest groups. The final blow is when we realise that all of the checks and balances are no such thing. They all seem to be connected together in their self-serving, defensive, herd-like behaviours and only benefit each other.
        Kindest regards, Zara. xxxx


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