By Vivienne Russell | 19 June 2013
The Care Quality Commission has apologised after an independent review found its checks on maternity services at a Lancashire NHS trust were ‘poor’ and provided the public and other regulators with false assurances.
A CQC team reviewed services provided by University Hospitals Morecambe Bay NHS Foundation Trust in 2009 after being alerted to concerns about maternal and baby deaths. But it concluded there were no major issues at the maternity unit and subsequently registered the trust without conditions in 2010. The CQC’s assurances also led Monitor to authorise the trust for foundation status in October 2010.
Despite this, serious incidents continued to occur at the trust, including another baby death in October 2011. The following month the trust was identified as having the highest mortality rates in England. Breach notices and warnings were issued by both Monitor and the CQC throughout 2011 and 2012 and a whistleblower on the CQC board repeatedly raised concerns about regulatory failure.
In September 2012, David Behan, the then new CQC chief executive, commissioned Grant Thornton to review the CQC’s registration and monitoring of the trust. Grant Thornton's report, published today, found serious failures of leadership and governance.
Of particular concern was an ‘apparent decision in March 2012 to delete [an] internal report’ into CQC’s regulatory oversight at the trust. However, Grant Thornton said it could find no evidence of a systematic cover-up and no basis for allegations that the former CQC chief executive put pressure on the health service ombudsman not to investigate a particular case.
‘The example of how an internal report was dealt with is evidence of a failure of leadership within CQC and a dysfunctional relationship between the executive and the board,’ the CQC said today.
‘There is evidence of a defensive, reactive and insular culture that resulted in behaviour that should never have happened.’
The CQC stressed that, since the events covered by the review, it had completely changed its executive team and made substantial changes to the board.
It added: ‘We let people down, and we apologise for that.’
CQC chair David Prior said Behan had been right to commission an independent report into the CQC’s handling of the registration and subsequent monitoring of UHMB and right to publish it in full.
‘The publication draws a line in the sand for us,’ he said.
‘What happened in the past was wholly unacceptable. The report confirms our view that at a senior level the organisation was dysfunctional. The board and the senior executive team have been radically changed.’
Former CQC chief executive Cynthia Bower resigned in February 2012 after the Department of Health issued a critical review of the regulator, saying it had not always focused on its core purpose. Former chair Dame Jo Williams announced she was standing down the following October, although she remained in post until Prior took over in January this year.
