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.|
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