Ivy Atkin’s death & more CQC evasion

By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 5 October 2017


The CQC catastrophically failed Ivy Atkin and other vulnerable residents at Autumn Grange care home in Nottingham, where patients were horrendously neglected and suffered unexplained injuries.

Ivy Atkin died on 22 November 2012 as a result of severe neglect. Inexplicably, it seems that on the final inspection of Autumn Grange when CQC inspectors found her gravely ill, she was not taken to hospital. Instead, she was transferred to another care home where she died after three weeks.

CQC did not carry out any internal review of its failures for four years, and it has still not properly accounted for its omissions in the Autumn Grange affair.

It has not answered a question about why Ivy Atkin was not taken to hospital.

The local authority has published only an executive summary of the Serious Case Review into Autumn Grange.

Remarkably, despite the fact that David Behan gave an undertaking last year that an internal review of the matter would be published, CQC has had a change of heart and is now trying to conceal the full contents of this document.

I have made a formal complaint about this extraordinary secrecy and arbitrariness.

Moreover, as CQC has now admitted under FOIA that it has asked for some of its responses to coroners’ Section 28 reports not to be published, I have asked CQC if it asked for its response on Ivy Atkin’s death to be withheld.

I hope Sir Robert Francis is re-thinking his comments to me of 19 January 2017:

“Of course nothing is perfect and the organisation recognises this:…under the leadership of David Behan, it is constantly – and openly –  striving to improve the way it regulates the sector”


Complaint to CQC Chair cc CQC Board, Philip Dunne Minister of State for Health and others:


Peter Wyman

Care Quality Commission Chair

5 October 2017


Dear Mr Wyman,

CQC’s handling of Ivy Atkin’s death, matters at Autumn Grange and issues of transparency and accountability

I write to raise a complaint about CQC’s handling of its failures concerning Ivy Atkin’s death and the related matters at Autumn Grange.

This is separate to a request for general internal review of CQC’s response to FOIA request IAT 1718 0390 which I will address under separate cover.

Ivy Atkin died a horrific death on 22 November 2012, weighing only 3st 13lb, having lost half her body weight over 48 days stay at Autumn Grange care home. Her body mass index was 10.7, which is at the outermost limit of survival. She was found close to death at Autumn Grange. She had pneumonia and an infected grade 4 pressure ulcer, contaminated with faeces. Her bed was soaked with urine. 1

When Ivy Atkin was discovered in extremis by CQC inspectors and the police she was reportedly not taken to hospital, but transferred to another care home where she later died three weeks later. 2

Other residents at the home were also found in a most neglected state:

“…mattresses were sodden with urine, there was no hot water or incontinence pads and residents were wearing each other’s clothing and even underwear” 1 

A spokesperson for the CQC reportedly stated:

 “The level of care at Autumn Grange was unacceptable and our inspectors were truly shocked by what they found.” 1

Private Eye reported in February 2016:


“Ivy who had dementia, wasn’t the only resident suffering gross neglect. After an anonymous carer blew the whistle, at least two residents were found to have pressure sores which were not treated properly; others were found lying in their own urine or waste; another had long, filthy nails digging into the skin, and yet another was found dehydrated with cracked and bleeding lips. Others had “unexplained injuries and bruising”, including head wounds, bruised and swollen hands and cuts to the knees and eyes of people who were immobile. Painting a horrific picture of staff “care”, one resident complained to inspectors about noisy nights. “Depends on which gang is on. They shout at the barmy ones,” he said. There was no hot water to wash those who were in a filthy state, and call bells were either not working or deactivated.” 2



The care home owner was subsequently convicted of manslaughter for the criminal negligence that resulted in Ivy Atkin’s death. 1 3 It was reported that expert evidence drew a causal link between the poor care and Ms Atkin’s physical decline and death. 1

Yet CQC had determined that Autumn Grange was largely compliant in the weeks prior to her death in 2012:


Screen Shot 2017-10-05 at 12.33.52



In February 2016 the CQC told Private Eye “..if there are further lessons to learn as a result we will ensure we do so”.

In relation to this, I asked David Behan on 18 February 2016 if CQC had conducted any internal review of its regulatory failure:

Dear Mr Behan,

Re Autumn Grange, the death of Ivy Atkin and CQC’s role

I see that the latest Private Eye reports concerns that CQC did not detect (or act upon) very serious failings at Autumn Grange care home, and concerns that the death of Ivy Atkin, 86 in 2012 was related to this.

I copy below the salient extracts from the Private Eye article. 

As the CQC has undertaken an internal review into why it gave Homerton maternity services a “good” rating in 2014, when this followed by at least Rive subsequent maternal deaths and findings of service failings at inspection a year later, may I ask if CQC has undertaken a similar internal review of the matters at Autumn Grange?

If such an internal review has been undertaken, please could a copy of this be made available and published.

Whilst I understand that a serious case review regarding Autumn Grange is now underway, may I also ask if there has been any previous examination of why Ivy Atkin was reportedly not admitted to hospital in October 2012 when she was found to be in such serious medical condition, but reportedly only transferred to another care home where she died three weeks later, despite CQC and all agencies presumably being aware of the serious medical condition in which she had been found?

Yours sincerely,

Dr Minh Alexander

I received an unfortunate response to this enquiry from the CQC Head of Inspection for the Central Region. He told me that although CQC had not undertaken an internal review, it was his view that CQC regulatory processes were “better than ever before”. 4

The CQC Head of Inspection did not address my question about why Ivy Atkin was not taken to hospital despite CQC inspectors finding her in extremis.

The executive summary of a Serious Case Review report produced for Nottingham City Council later stated that CQC accepted their inspection in September 2012 should have been more rigorous”. 5

But it was only after damning coroner’s findings on Ivy Atkin’s death and a related Section 28 Report on Action to Prevent Future Deaths issued on 25 October 2016 that CQC gave any public indication of internal review regarding Autumn Grange. 6


The coroner’s Section 28 report of 25 October 2016 on Ivy Atkin’s death, sent to CQC as a named respondent:


CQC’s did not respond to the coroner within the statutory deadline and its response was not published by the Chief Coroner until August 2017, after I queried its absence:




CQC informs me that the internal review took place in August 2016.

However when I recently asked for a copy of the internal review, CQC resisted disclosure on grounds that it would infringe CQC staff privacy:



We consider CQC’s full Internal Review into this matter to be exempt from disclosure as the reports contains personal information and identifies individual inspectors and disclosure could severely impact their privacy if they were identified. This exemption is explained in full in the ‘Exemptions on disclosure’ section below.

 From a CQC response received 4 October 2017



This is an extraordinary FOIA exemption to rely upon in a case of unlawful killing where the regulator has admitted that its actions were wanting.

CQC’s attempt to protect itself in this manner also seems all the more questionable given that David Behan CQC CEO previously assured the CQC Board on 16 November 2016 that this internal review would be published:



We expect to publish our internal review into our regulation of Autumn Grange Residential Home alongside the summary of the Council’s Safeguarding Adults Review.”




CQC has gone to trouble of producing a manicured summary of its withheld internal review on Autumn Grange, which emphasises that the coroner was satisfied by CQC’s assurances that things had ‘moved on’:


There is ample evidence that things have not ‘moved on’ and that CQC continues to fail very vulnerable care home residents. 7 8 9

CQC’s failure to act on the appalling, similar death of Barbara Cooke in 2014 despite receiving a coroner’s Section 28 report is a case in point. 10 I should point out that there is still no published CQC response to the Section 28 report issued on 12 September 2014 about Barbara Cooke’s death.

It is inappropriate of CQC to suggest that the public should settle for a summary of its withheld internal review report on Autumn Grange.

Given that CQC has now just been exposed for covering up the likely rape of a highly vulnerable man in another care home 11, I think this filtering of information by CQC is especially unwelcome and that the negligent, horrific death of a vulnerable person requires full transparency.

CQC conceded only four weeks ago that external review was required in the case of the above covered up rape. It is simply not credible for CQC to assert that a filtered version of an internal review is adequate accountability for Ivy Atkin’s terrible death.

Under even the much criticised old CQC regime, Cynthia Bower and Jo Williams arranged an internal review of CQC’s notorious failures at Winterbourne View that was published. 12 And nobody died in that episode.

CQC’s summary of its internal review on Autumn Grange raises more questions than it answers.

Unsurprisingly, CQC admits fleetingly in its summary of the internal review that it failed to listen to whistleblowers:



The review identified a number of areas where improvements were required. There was too much focus on the evidence collected the day of the inspection in September 2012 rather than ensuring that our methods for assessing the provider’s regulatory risk was based on all the information available including past regulatory history, whistleblowing and safeguarding referrals and concerns from other agencies. The review also identified that record keeping, storage of information and inspection planning was poor.

 Undated CQC summary of its internal review on Autumn Grange and Ivy Atkin’s death



I believe it is incumbent on CQC to explain in greater detail exactly what whistleblower intelligence it received about Autumn Grange prior to Ivy Atkin’s death and why it failed to act upon this intelligence.

This is because these matters remain relevant and CQC continues to fail whistleblowers by not listening to them or even being complicit in reprisal against them. 13

A recent FOI disclosure by CQC relating to HC-One, one of the largest care providers, suggests that CQC still gives insufficient weight to whistleblower intelligence. 14

I think given the gravity of the matters in question CQC should publish its internal review on Autumn Grange in its entirety, and provide the public some assurance regarding the competence of inspection staff involved and whether they remain employed by CQC.

If CQC is not willing to provide such assurance, I feel the very least that CQC should do is disclose and publish the internal review with redaction of individual CQC staff details.

I should point out of course that the CQC may not rely on a privacy exemption under the FOIA where information is already in the public domain.

Your inspector for Autumn Grange is already named on the public record and reported to have stated that she found “chaos and screaming” upon the final Autumn Grange inspection, but that she maintained that “A home can go downhill quickly”. 15

It was also reported:

“Under questioning from Nottinghamshire Assistant Coroner Stephanie Haskey, Mrs W said she had not “missed anything” in an earlier inspection in September.”


To summarise, I am concerned that:

  • CQC did not see fit to undertake an internal review until four years after Ivy Atkins death.


  • CQCs Head of Inspection appeared in his letter to me of 2 March 2016 to be dismissive of the need for internal review and despite the absence of review, claimed that things were better.


  • CQC has refused to disclose a copy of its internal review and it has not published its internal review despite this being originally promised by David Behan.


  • CQC has given inadequate and frankly spurious reasons for not making the full contents of its internal review public. CQC has failed to act appropriately on the most serious public interest issues possible.


  • CQC has still not addressed my original question of why Ivy Atkin was not taken to hospital when CQC inspectors found her gravely ill.


Moreover, now that CQC has admitted that it has asked that some of its responses to Section 28 reports should not be published by the Chief Coroner, I would be grateful if CQC would clarify whether it initially asked for its response to the Section 28 report on Ivy Atkin’s death not to be published by the Chief Coroner.

In short, CQC cannot have the moral authority to demand transparency of regulated bodies if it is not willing to model the same behaviour and values.

Yours sincerely,

Dr Minh Alexander


Sir Robert Jay Queen’s Bench Division, High Court

Ms Stephanie Haskey Ass Coroner Nottinghamshire

Ms Mairin Casey Coroner Nottinghamshire

Judge Mark Lucraft Chief Coroner

Elizabeth Denham UK Information Commissioner

Lord Bew CSPL

Sir Amyas Morse NAO

Public Administration and Constitutional Affairs Committee

Public Accounts Committee

Health Committee

Philip Dunne MP Minister of State for Health

Dr Philippa Whitford MP

Norman Lamb MP

Jon Ashworth MP Shadow Secretary of State for Health

Barbara Keeley MP Shadow Minister for Mental Health and Social Care

Sir Paul Jenkins, Matrix Chambers

Sir Robert Francis QC CQC NED

Prof Louis Appleby CQC NED

Paul Corrigan CQC NED

Paul Rew CQC NED

Jora Gill CQC NED

Ted Baker CQC Chief Inspector of Hospitals

Andrea Sutcliffe CQC Chief Inspector of Adult Social Care

Steve Field CQC Chief Inspector of General Practice

Mike Mire CQC NED and Chair of CQC Regulatory Governance Committee

Malte Gerhold CQC Executive Director of Strategy and Intelligence

Jane Mordue CQC NED and Chair Healthwatch England



CQC’s “better than ever”…or didn’t you know?


CQC an ongoing concern


Care home deaths and more broken CQC promises




1 http://www.nottinghampost.com/news/nottingham-news/ivy-atkin-death-care-home-138551

2 Autumn’s Fall. Private Eye February 2016, Issue 1412

3  http://www.bbc.co.uk/news/uk-england-nottinghamshire-35499865

4 https://minhalexander.files.wordpress.com/2016/10/cqc-no-internal-review-of-autumn-grange-death.pdf

5 https://minhalexander.files.wordpress.com/2016/09/safeguarding-adults-review-executive-summary-autumn-grange.pdf

6 CQC Chief Executive report to the CQC Board 16 November 2016


7 Elderly people put at risk as watchdog fails to act on warnings of fatally negligent care homes, Melanie Newman and Oliver Wright, Independent 2 September 2015


8 Public Accounts Committee, report of Inquiry on CQC, 11 December 2015 https://publications.parliament.uk/pa/cm201516/cmselect/cmpubacc/501/501.pdf

9 Care home deaths and more broken CQC promises, Minh Alexander 8 October 2016


CQC an ongoing concern, Compassion in Care December 2015


10 Death of Isle of Wight care home resident at centre of national investigation


Section 28 report on Barbara Cooke (for which there is still no published CQC response)


11 Three Times articles published on 27 July 2017, related to CQC cover up of a suspected rape and other incidents at care homes run by Hill Green Care




12 CQC internal management review of the Winterbourne View affair 2011


13 CQC breach of whistleblower confidentiality and complicity in reprisal


Letter to Public Accounts Committee 11 September 2017


CQC denies denial


14 The FOI data on HC-One disclosed by CQC, regarding information of concern received by CQC on all HC-One providers:


Screen Shot 2017-10-05 at 22.54.21

Source: FOI disclosure CQC IAT 1617 0235 via the ‘What Do They Know’ site



Five out of the top eight HC-One care homes with the highest number of whistleblowing contacts recorded by CQC, between Jan 2013 to June 2016, are currently rated ‘Good’ overall by CQC:

Screen Shot 2017-10-05 at 23.08.10

Source: FOI disclosure CQC IAT 1617 0235 via the ‘What Do They Know’ site

https://www.whatdotheyknow.com/request/hc_one_care_home_operator#incoming-848034 and published CQC inspection reports as of 17 September 2017

15 http://www.bbc.co.uk/news/uk-england-nottinghamshire-37621522

4 thoughts on “Ivy Atkin’s death & more CQC evasion

  1. Sincerely hope that, one day, you will receive a useful response to the excellent and vital points that you raise.
    I’m exercising great self-discipline in not saying what I want to say.
    Instead, I shall thank you and continue to apply my beady eye to the characters within our institutions who are responsible and could do more if they so wished, yet don’t.


  2. This is appalling. My heart goes out to this poor lady and all those who loved her.

    What is even more shocking is that inspectors on the day found her like this. Clearly she was medically compromised and one of them should have had the common sense and decency to call 999 and get her admitted to a place of safety that could have treated her. That would have given her a fighting chance at least.

    IMHO those inspectors were as negligent as the care home owners. No wonder the CQC are protecting their own through alleged FOI “exemptions”. Pity they are not so pro active in other areas.

    The only thing transparent about the CQC is their deliberate opaqueness when called to account.

    I would also lay real money there was whistle blowing intelligence available to the CQC before the time that carer went to the adult safeguarding crisis team and everyone was then forced to act. It was then far to late.


  3. Hi Helen, CQC need to come clean and set out exactly what whistleblower intelligence they received before the final events at Autumn Grange. We know that there was at least one concern raised by a care worker in 2010 because CQC admitted to it – “elderly man put in a headlock at care home” – just horrendous:



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