Elderly people put at risk as watchdog fails to act on warnings of ‘fatally negligent’ care homes

The Independent     2 September 2015
  Exclusive: Reports fail to trigger inspections by the Care Quality Commission

The lives of vulnerable care home residents were put at risk because England’s healthcare regulator failed to act promptly on official warnings about fatally negligent standards, an investigation for The Independent reveals.

Coroners’ courts have identified more than 20 deaths of care home residents in the past two years that could happen again without changes in practice.

Yet in more than half of these cases, research by the Bureau of Investigative Journalism has found, these reports failed to trigger inspections by the Care Quality Commission (CQC).

The commission has admitted its response to the warnings had “not always been consistent” and was working to improve the situation.

But charities working in the sector claimed that the regulator “loses vital information in its systems all the time”.


David Behan, chief executive of the CQC, said: “I am not going to defend the indefensible. We have got more to do.”

The investigation by the bureau examined 23 cases where an individual had died unexpectedly in a care home since July 2013.

In every case an inquest was held and the coroner went on to advise a care home or agency in England to take action to prevent another death from occurring.

But in nine of the cases, the homes and agencies involved were last inspected by the CQC before the deaths occurred up to two years ago. In a further two cases the homes were not inspected until long after the deaths, and six months after the coroner’s report.

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In another case, the CQC inspected the home in the two months between the unexpected death in September 2014 and the coroner completing a formal report in November.

The CQC did not mention the recent death in its review and there is nothing in its findings to show that inspectors had checked whether issues subsequently raised by the coroner had been addressed. The inspectors have not returned to the home following the coroner’s report.

The bureau found four further cases where the homes were inspected within a few months of the coroner’s report. But in none of these cases did the CQC reports mention either the inquest or whether the inspection had checked to see if the coroner’s concerns had been addressed.

In the remaining seven cases, providers had been inspected promptly after the coroners’ warnings and it is clear in the CQC reports that the issues raised had been looked into.


The CQC is not obliged to inspect in every case, but has a range of options in responding to a coroner’s warning notice, such as reviewing any proposed action plans from the care home in question, meeting with them to discuss action taken, and agreeing action with others, such as local safeguarding teams.

In one case, a coroner found nursing home staff had failed to recognise that an elderly lady was “acutely unwell” because they were not properly trained.

After she died in August 2013, the home also failed to investigate properly and wrongly told the CQC that internal protocols had been correctly followed when they had not been, according to the coroner’s formal report.

After the inquest, the coroner produced an official document in January 2014 , known as an “action to prevent future deaths” report – a process introduced in July 2013 – which was sent to the CQC.

The home has not been inspected since. It was last inspected in May 2013, when it received a positive score on all counts, including for staff training.

The bureau’s findings raise disturbing questions about how the CQC prioritises inspections and acts on information it receives.

Eileen Chubb, the founder of campaigning charity Compassion in Care, said: “In our experience, the CQC loses vital information in its systems all the time.

“We get a huge amount of information coming in that needs acting on immediately and we are a small organisation with a tiny budget. The CQC does not seem to be capable of dealing with all the intelligence it receives.”

Judy Downey, the chair of the Relatives and Residents Association, which supports care home residents and their families, said: “The lack of rigorous follow-up and appropriate enforcement action by the CQC in relation to incidents and unexpected deaths, even where prosecutions have taken place, continues to be a huge cause for concern.”

Mr Behan said that since the cases had arisen the commission had undertaken a review of its procedures and was now working with coroners to ensure that all warnings were promptly acted upon and came to one central point in the organisation.

“We are not pretending we have got this cracked. We are radically changing the way in which we regulate health and social care in this country. Have we finished that task? No we haven’t. We have got more to do. We absolutely understand this issue.

“We understand this is about people, and people having the confidence and trust that they will be kept safe in the care that they receive, and we’ve got more to do.”

Duty under the law

Coroners have a duty under law to make reports to organisations including the CQC – as well as local authorities, government departments or agencies – when they believe that action should be taken to prevent future deaths. All reports and any responses are also sent to the Chief Coroner, and they are published on Judiciary Service’s website.


CQC response to story in The Independent

3 September 2015

A story has been published in The Independent today (Thursday 3 September) focussing on CQC’s response to Regulation 28 reports, which are issued by the Coroner and aimed at preventing future deaths.

The story focusses on a number cases (between 2013 and 2015) where someone died – either in a care home or following care or treatment at home – where the Coroner concluded that further action needed to be taken to prevent a future death in similar circumstances from occurring.

Our Chief Executive, David Behan, gave an interview to The Independent to explain how CQC has improved the processes we have to in place to ensure that we respond to and learn from the issues highlighted by these Regulation 28 reports.  

CQC’s Chief Executive, David Behan, said:.

“When someone dies while being cared for in a health or social care setting and the Coroner concludes that action is needed to prevent future deaths from occurring, a Regulation 28 report is issued. In most cases, the provider will be the named respondent, meaning that they have responsibility for preventing a future death in similar circumstances.

“In some cases, however, CQC is the named respondent, meaning that the Coroner has concluded that the regulator also has a role to play in ensuring that people are protected in the future.

“In those cases where CQC is identified as the named respondent, it is absolutely right that we should expect CQC to use this information to inform our regulatory activities. This includes how we respond to levels of risk as well as ensuring providers act on the recommendations of Coroner’s Reports.

“Last year, I initiated a review of our processes and procedures, as I had recognised that we were not always receiving these Reports. In some cases where we did, it was also clear we were not always dealing with these effectively enough.

“We have made a number of changes to strengthen and tighten our ways of working, including:

  • Establishing a single point of contact for Coroners’ reports to ensure any concerns raised are effectively logged, analysed, managed and reviewed.
  • Better and earlier engagement with Coroners around the time of a person’s death.
  • A proposed and drafted Memorandum of Understanding with the Coroners’ Society to strengthen our working relationships and ensure we receive all Coroners’ reports in health and social care inquests in order to help reduce risk more effectively and promptly.

“We’ve made progress, but I’m far from being complacent. We know there is more work to do. Improvement is a continual commitment and we are making sure we are properly embedding our new process, further developing our relationship with the Coroners’ Society and being really clear about what we expect our staff to do when they receive these types of reports.

“But this isn’t just about processes – it’s about people’s lives.  For that reason, we need to keep working hard to ensure that we get it right every time.”

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