How are CQC inspectors supposed to assess learning from deaths? Disclosed internal guidance for CQC inspectors

Dr Minh Alexander NHS whistleblower and former consultant psychiatrist 23 February 2019


 Summary: The Care Quality Commission has reluctantly disclosed internal guidance on how its inspectors should handle patient deaths and related matters. Links to the disclosed documents are provided below.


Brief background

The ongoing, patchy learning by the NHS from avoidable patient deaths is a festering governance sore.

After all the disasters and endless inquiries, too little progress has been made.

The victims of the unnatural deaths at Gosport War Memorial have still not seen justice and the government still fiercely resists prosecutions despite the damning conclusions of the Gosport Independent Panel last summer.

The key MidStaffs Public Inquiry recommendations such as safe staffing and robust whistleblower protection lie in ruins, whilst those responsible for the harm and who were criticised by the Inquiry continue to be recycled.

The stark Mazars’ findings about Southern Health NHS Foundation Trust’s serious negligence in failing to investigate hundreds of deaths have also been deftly derailed. Sham system responses have led nowhere.

But nevertheless, it can be useful to families and whistleblowers to know what the ground rules are, when trying to navigate the system.

To that end, I asked the Care Quality Commission (CQC) to disclose internal guidance for its inspectors on handling deaths, human rights issues and the management of ligature points.

CQC dragged its feet, then initially tried to brush the request off by referring me to its guidance for service providers.

After yet more email soft shoe shuffle from CQC, and over seven weeks after I asked for the information, CQC finally disclosed the following documents:



CQC FOI Disclosure 21 February 2019

CQC Learning from Deaths Monitoring and Inspection Tool – Long Guide (Interim Guidance draft 5 September 2017)

CQC Equalities and Human Rights guidance materials

How to manage statutory notifications under Regulation 17: Deaths of detained patients

Brief guide for inspection teams – Ligature points

Brief guide: substance misuse services – ligature risks



Screenshot 2019-02-23 at 06.35.42



Who knew what, and when, at Mid Staffs? Philip Carter and Prof Brian Jarman BMJ 6 February 2013

Entering the labyrinth; a leder tale by @sarasiobhan mother of Connor Sparrowhawk who died at Southern Health NHS Foundation Trust

New website under construction by the family of Elsie Devine who died at Gosport: see @ann_poppy  and @bee_devine

Witness statements about concerns at Gosport War Memorial Hospital

Covering up cover ups: CQC’s revisionism

CQC Deaths Review: All fur coat….

















3 thoughts on “How are CQC inspectors supposed to assess learning from deaths? Disclosed internal guidance for CQC inspectors

  1. Thank you for this post.

    You are certainly building a formidable body of evidence which will hopefully one day overturn the corruption within our endemically pathetic, wicked, bureaucratised and parasitised health service.

    I have to confess that I will not have time to read the CQC FoI disclosures – an evident pleasure for another day.

    However, as the irresponsible show little or no interest in helping, or learning from, those patients and the relevant medical staff who are still alive, I am not surprised they show little enthusiasm for learning from the patients once they are dead and safely ‘covered up.’

    Although I have a feeling, the irresponsible would shine if asked to demonstrate the arts of ‘covering-up.’

    Kindest regards,


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