Care watchdog ‘fails to follow up on coroners’ death warnings’


The care watchdog is failing to order urgent inspections of care homes, despite coroners warning that urgent action must be taken to prevent further deaths of the disabled and older people who live there, an NHS whistleblower has found.

Coroners publish Prevention of Future Deaths (PFD) reports after holding inquests in which they have concluded that organisations – such as residential and nursing homes – or individuals need to change procedures or policies to prevent further similar deaths.

Concerns were first raised by The Independent in September 2015, which revealed that in more than half of the more than 20 cases in which coroners had written PFD reports following deaths in care homes, those reports had failed to trigger Care Quality Commission (CQC) inspections.

But Dr Minh Alexander (pictured), an NHS whistleblower and former consultant psychiatrist, has updated that research and says her findings show that CQC is still failing to act on PFD reports, despite it promising last year that it would improve.

David Behan, CQC’s chief executive, said last year that he was “not going to defend the indefensible” and that the commission had “more to do” in responding to PFD reports, while promising that any concerns raised in PFDs would in future be “effectively logged, analysed, managed and reviewed”.

But Alexander has looked at 66 PFD reports on care home deaths since July 2013 and says they show that CQ is still failing to act.

She says that CQC has failed to inspect 18 of those homes after the reports were published.

Among concerns raised by the coroners were poor training, insufficient staffing, people being placed in homes that were incapable of meeting their complex needs, and safeguarding failures.

For homes that were eventually inspected by CQC following a PFD report, it often took more than a year for those inspections to take place, and in one case more than two years.

The commission appears to have taken more than a year to inspect a care home after a PFD report in 10 cases, and in another 10 is still yet to carry out an inspection more than a year after the PFD report was published.

Even in those cases where inspections did take place after a death, but before a PFD report was written – with CQC acting before it was notified of concerns by a coroner – there were still many lengthy delays, says Alexander.

Of the more than 50 care homes inspected following deaths that led to a coroner’s PFD report, it took an average of seven months before the watchdog carried out an inspection, says Alexander.

Most inspection reports failed to even mention the deaths or the PFD reports, she said.

Alexander told Disability News Service (DNS) that she believed the commission was contributing to suppressing the truth about the state of public services.

She said: “As I see it, the CQC is a political device to allow Department of Health deniability, and for selling a political story of tough regulation and government action on care quality, whilst hiding the truth about the destruction of public services.”

She added: “It seems to me that after last year’s embarrassment, CQC improved a bit in its handling of new coroners’ warnings (but was still a bit slow and variable) but it didn’t bother to check and act on the older cases that had been neglected.

“It’s a fly-by-night operation that concentrates on how it looks, and doesn’t bother too much if it thinks no-one can see.”

She said the CQC’s “floundering” response to her concerns – after they were forwarded to the commission’s press office by DNS – suggested that it was not familiar with the data and “has not kept its promise a year ago to proactively collate, track and analyse coroners’ warnings”.

She said: “The continued variability in intervals between PFDs and subsequent inspections also suggests CQC still does not effectively coordinate its responses to coroners’ intelligence.

“This is two years after it claimed it had arranged to receive all coroners’ reports from health and care settings.”

Alexander added: “The CQC often tries to wriggle out of hot water by saying that it is ‘learning by doing’, etc, but it is a multi-million pound business from which we should reasonably expect more professionalism.”

She has now written to both the Commons health and public accounts select committees, with details of her research, hoping that MPs will hold the watchdog to account when they next question its senior figures.

In her email, she criticised CQC’s “seven years of failure” since its launch in 2009, and said that its approach “does not work, is not safe and is poor value for money”.

When asked to comment on Dr Alexander’s figures, the commission released the following statement from its chief inspector of adult social care, Andrea Sutcliffe, who said: “The Care Quality Commission is committed to using information from coroners to support our work in making sure health and social care services provide people with safe, effective, compassionate and high-quality care and holding providers appropriately to account.

“We have previously acknowledged that our handling of reports from coroners has not been sufficiently effective which is why we carried out an internal review in 2014, introduced new procedures in 2015 and established a formal agreement with the Coroner’s Society in November 2015. 

“I believe that we are now much better at making the right decisions at the right time so we respond to risks robustly and in a timely fashion.

“In particular, I do not expect inspectors to wait for risks to be identified at inquests, which may happen some time after the death of somebody using a service, but to respond proactively and appropriately when we are first notified.

“Our response may include an inspection, but it may also include following up on action we have already required the provider to take.  

“We are also looking to improve our own practice, for example, we are planning to introduce standard wording in our reports to outline the reason for the inspection, including when this is in response to information from the coroner.

“Everyone using care services deserves to experience great care and to know they are safe. As the regulator we are determined to do our part to make this a reality.”

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