The NHS Ombudsman is criticizing CQC for failing to fully investigate the boy’s death
The NHS Ombudsman has criticized the service’s care regulator for failing to properly investigate the death of a five-year-old boy in a specialist ward.
The boy’s foster mother – an NHS doctor – has accused the care provider who cared for him of instigating “a cover-up” over how he died and frustrating her efforts to uncover the truth.
The ombudsman has criticized the Care Quality Commission (CQC) for failing to act on evidence that emerged during the inquest into the boy’s death and which cast doubt on the trust’s version of events.
Ombudsman Rebecca Hilsenrath’s ruling is another blow to the credibility of the CQC, which was declared ‘not fit for purpose’ by Health Minister Wes Streeting in July.
The case shows that the various regulators that oversee healthcare must ensure that when mistakes are made, the healthcare provider shows transparency and responsibility, Hilsenrath said.
The ombudsman did not mention the boy by name. He had a neurological disability and lived in Sheffield with his foster parents, who cared for him since he was six months old. He was found dead in his cot one morning in May 2017, six weeks after a stay at a specialist children’s home in Tadworth, Surrey, run by the Children’s Funda charity.
He was doing well and had no major underlying physical or medical problems. Initially the CQC believed his death had been natural, based on what the charity had told it.
But the inquest into his death found it had occurred after a loose padded bumper around his bed, to prevent injuries or falls, became loose and became wedged under his neck. It was determined that he had died “after being trapped by a loose bed bumper, causing death from airway obstruction.”
The boy’s foster mother, who wished to remain anonymous, complained to the CQC and, unhappy with the response, raised her concerns with the ombudsman.
“When something goes wrong in healthcare, there must be accountability and lessons must be learned. If that doesn’t happen, grieving families suffer the added pain of having to fight harder to get the answers they are looking for,” Hilsenrath said.
“Regulatory organizations must ensure they investigate all available evidence to uncover the truth for everyone involved and prevent others from experiencing the same trauma.”
Dr. Karen Henderson, the coroner who heard the inquest, was so concerned by the evidence about the Children’s Trust’s conduct that she released a report on the prevention of future deaths – a legal warning that the dangers of the same events must be eradicated to protect patients to protect.
In the report she highlighted that police and coronavirus staff who visited the trust shortly after the boy died were “not fully informed of the circumstances of his death”. For example, they were not told in what position his body was found, that he had been dead ‘for some time’ or that the bumper had been found over his neck.
The trust “failed to acknowledge that there was a lack of transparency and openness about the manner in which (the boy) died or that the trust had failed to properly investigate his death or inform the relevant statutory authorities of the circumstances of his death” , the coroner added.
Following the inquest, the Children’s Trust said it accepted the coroner’s findings and apologized to the boy’s family. A statement at the time said: “Our senior leadership team has established an action group dedicated to developing new processes and systems that will address the coroner’s concerns.
“This is in addition to the measures we had already taken in the past five years after (the boy’s) death; including new beds and cots, and changes to our night-time monitoring policy.”
Speaking to the Guardian, the boy’s foster mother said: “I think there is no doubt that there has been a cover-up (by the trust). I feel really angry. I feel like (her son’s) life didn’t matter.
“The CQC should have been much more curious. As a doctor I am used to dealing with the CQC. But I have lost confidence in an organization that should be doing its utmost to ensure that places that care for vulnerable people are safe. They didn’t see that things were wrong here.
“It felt like the CQC was there to protect its trust and reputation. Only the ombudsman gave me answers, because they didn’t want to give me answers.”
James Bullion, the CQC’s chief inspector of adult social care and integrated care, acknowledged the regulator had failed the boy’s family.
“Everyone has the right to expect safe, high-quality care and a regulator who can be trusted to act in the interests of themselves and their loved ones. We were failed in this matter and we deeply regret the impact this has had on the family of this young boy.”