What’s the point of CQC’s Emerging Concerns Protocol? CQC never once triggered it at UHB nor held a regulatory risk summit in the four years up to 31 March 2022

Dr Minh Alexander retired consultant psychiatrist 29 April 2023

The Parliamentary and Health Service Ombudsman told BBC Newsnight that it triggered this protocol for the first time ever at University Hospitals Birmingham NHS Foundation Trust in the summer of 2022 because of concerns about UHB’s culture and leadership, with respect to learning from serious incidents.

PHSO advised me it attended multi-agency meetings about its concerns on UHB on 4 August 2022, 12 October 2022, 10 January 2023 and 7 February 2023.



Man died after medical staff missed opportunities to identify abnormalities on abdominal x-ray

A 65 year old man died avoidably at UHB in 2019 of intestinal obstruction after doctors failed to interpret clinical signs and read an abdominal x-ray correctly.

His sister was wrongly told that he had constipation and dehydration.

His family were awarded compensation in the higher PHSO range of £10,000.

The Care Quality Commission’s Emerging Concerns Protocol for data sharing between regulators says that no concern is too small to invoke the protocol.

I asked CQC if it had ever triggered this protocol at UHB.

CQC’s FOI reply of 28 April 2023 revealed that it had never done so, not even after receiving the dossier from UNISON in July 2021 about extensive UHB staffside concerns regarding unsafe staffing and poor management behaviour. Or the FPPR referrals on Rosser the former UHB CEO or the blood products never events.

Consistent with this lack of action upon the UNISON dossier, CQC indicated that it had not attended any regulatory risk summit meetings on UHB in the four years prior to 31 March 2022.

“CQC did not attend, and does not hold information about, any regulatory risks summit meetings (or similar) held about UHB in the 4 years up to 31/03/2022”.

CQC refused to say what regulatory risk summit meetings it had attended since then:

CQC will not disclose whether or not we have attended any regulatory risks summit meetings (or similar) about UHB since 01/04/2022 as disclosing recent information about this type of activity would be likely to be prejudicial to the exercise of our regulatory functions.”

The regulator implied that information sharing had occurred outside of its emerging concerns protocol:

“It should be noted that the ECP is not the only mechanism or legal framework for regulators to share information. Nor is it designed as a mechanism for sharing only the most serious or substantial information of concern.”

However, the lack of any regulatory risk summit meetings in the four years up to 31 March 2023 suggests that CQC simply did not consider there were serious problems at UHB (or alternatively did not wish to acknowledge them).

It was not until after the first BBC Newsnight broadcast that CQC carried out the unannounced inspections in December 2022 which led to the recent issue of a warning notice about unsafe staffing, which UHB have been whistleblowing about for years now.

CQC reported from this inspection that levels of staffing were so low that vulnerable patients were having falls and some had sustained injuries DURING this inspection. 

Trust board papers show that falls with serious or catastrophic injuries are a regular occurrence. 

Why is CQC simply issuing a warning notice and not conducting a Regulation 12 investigation given the history of repeated unsafe staffing and regular falls with serious patient injuries? 

Probably for the same reason that it did not act on UHB staff concerns in the first place and continued to rate the trust as ‘Good’ until the problems were exposed by the media.


Why is CQC not investigating UHB under CQC Regulation 12?

PHSO alleges it has been excluded from NHSE/ICB’s reviews on UHB & ICB’s factual inaccuracy to the Joint Health Overview and Scrutiny Committee

Can Healthwatch Birmingham please let us see its complaints & concerns data on UHB?

Bewick’s lack of data on suspended and disciplined UHB doctors, despite complaints of medical management cronyism

Bewick, the ICB, misinformation by UHB about GMC referrals and a late correction

Mr Tristan Reuser’s whistleblowing case: Scandalous employer and regulatory behaviour on FPPR

NHSE, ICB and UHB’s three-ring circus and Rosser’s digital assignment

One thought on “What’s the point of CQC’s Emerging Concerns Protocol? CQC never once triggered it at UHB nor held a regulatory risk summit in the four years up to 31 March 2022

  1. I can’t quite see the point of the existence of the CQC.
    All that I can think of is that they act as an obstruction – to prevent victims or their relatives from gaining access to the executives ultimately responsible for scandalous behaviour.


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