Dr Minh Alexander retired consultant psychiatrist 21 April 2023
Care Quality Commission Regulation 12 provides a facility for unsafe provider organisations to be investigated for failures to provide safe care and ultimately to be prosecuted.
Like many others, I fail to see the utility of fining cash strapped public bodies, which only hurts patients as the end users.
However, the regulation exists and CQC is obliged to apply it where appropriate and importantly, to investigate where there is evidence of organisational failure.
University Hospitals Birmingham NHS Foundation Trust staff have been whistleblowing to UHB management and to the CQC about unsafe levels of staffing for a long time.
UNISON sent a dossier to CQC in July 2021which revealed that UHB staff across all three sites had been raising concerns with trust managers about “depleted” levels of staffing since before the pandemic.
CQC did not publicly acknowledge the existence of this dossier.
The BBC revealed its existence in recent months as part of the coverage of the UHB scandal.
CQC carried out an unannounced inspection at Good Hope Hospital and Heartlands Hospital between 7 to 14 December 2022 shortly after BBC Newsnight’s first broadcast about UHB.
CQC claimed that it undertook the inspection because:
“We conducted an urgent, unannounced inspection of the full medical care core service due to a number of concerns raised by patients and their families around the care and treatment they had received.”
The reports from this latest CQC inspection was published on 19 April 2023.
The report from the Good Hope Hospital inspection was damning on management failure to respond to concerns, in that staff had stopped using the internal route for raising concerns because of zero expectation that managers who act upon them:
Deeply concerning was a CQC finding of very unsafe levels of staffing.
Related to this, patients suffered falls and suffered injuries DURING the CQC inspection:
The CQC issued a Section 29A improvement notice with respect to the unsafe levels of staffing:
A look at UHB’s annual quality report for 2020/21 shows variation between trust sites in the rate of falls per 1,000 occupied bed days
Research shows that falls can be reduced and prevented with good practice measures and safe staffing.
A UHB board paper issued under Lisa Stally Green former UHB Chief Nurse’s oversight (Stalley Green is now the ICB Chief Nurse) in 2020 revealed that there had been a steady stream of severe harm and catastrophic harm to patients due to falls suffered at UHB:
The former NHS England Serious Incident Framework used this categorisation for degrees of harm:
Whilst neck of femur fractures may not result in immediate death, and may therefore sometimes receive a short term categorisation of “severe” rather than “catastrophic” harm, such fractures in older people may trigger a downwards spiral that eventually leads to death:
Given that there have been both longstanding understaffing at UHB AND evidence of regular, serious harm from falls, should the CQC be investigating UHB for Regulation 12 breaches, and not just issuing an improvement notice?
Indeed, the falls related injuries are not the only evidence of possible Regulation 12 breaches at UHB.
With the issue of the CQC warning notice, are we witness more to spectacle, than meaningful regulatory action?
Have harmed UHB patients and their families tried to raise concerns with CQC, but been fobbed off with the classic but misleading CQC refrain “We have no remit to investigate individual complaints”?
Reframing concerns as “complaints” blocks whistleblowers, patients and families, and CQC often does not disclose that it does have a remit to investigate incidents of avoidable harm under Regulation 12.
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Patient and staff reports of avoidable harm should be investigated by safety experts and not treated merely as administrative complaints. Do no harm .
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Thank you for pursuing and reporting on this distressing scandal.
The only thought that I can offer is to suggest that the CQC amend its title to – “Couldn’t Care Less Quality Commission.”
I admit that’s a bit unkind, but at least it wouldn’t raise unrealistic expectations of professionalism as its present title might suggest.
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Look what I found earlier;
https://www.trustpilot.com/review/cqc.org.uk
Now everyone with the misfortune of having dealt with the CQC, can share their.
Make sure you do everything to promote this opportunity – because public exposure is how to hold them to account. Private communications with the CQC – only end up with obstruction and frustration, which is what their senior team are best at doing.
AND DONLT FORGET – YOUR LOCAL TRYST HAS A TRUSTPILOT LINK TOO – OR YOU CAN ESTABLISH ONE. Knowledge is power remember.
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For the CQC to find failure under Reg 12; Failure to provide Safe Care & Treatment, would potentially lead to criminal charges – which they, as a Crown Prosecutor could pursue., against the Trust or individuals. However, given the lengthy history of complaints that have been fobbed off the CQC and UHB, that could open a whole can of worms for them.
And ask your self why CQC Head of Hospital Inspections, Bernadette Hanney, left the CQC at the end of last year. Only to join Birmingham and Solihull Integrated Care Board, as Chair of their new Maternity Services Quality Oversight and Improvement Group!!!!! Coincidence or convenience??
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I agree that CQC is probably in a cleft stick. Also, safe staffing is a toxic political issue for CQC as if they take action against UHB, this would lead to questions about why they aren’t acting on many other instances of unsafe staffing across the NHS. It would ultimately lead back to the Department of Health and the failure to act on the Midstaffs Public Inquiry recommendation on safe staffing. Thanks for the information about the CQC Head of Inspections.
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…And don’t forget – the CQC’s Midlands Hospital Inspection teams based at Derby, cover a huge area. including UHB. the Shrewsbury & Telford Maternity scandal, the Nottingham Maternity scandal and Mid Staffs.
So how many more acute hospitals in that region are suffering similar undisclosed and overlooked omissions – that place patients at risk of avoidable harm???
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