To David Behan Chief Executive Care Quality Commission, 9 September 2016
Dear Mr Behan,
CQC’s reporting of coroners’ Reports to Prevent Future Deaths
I write to inform you of an irregularity regarding information about coroners’ Reports to Prevention Future Deaths.
In CQC’s annual Mental Health Act monitoring report for the period 2014/2015, it is reported that:
“Between December 2014 and June 2015, we received three ‘Prevention of future death reports’ concerning patients who were receiving mental health services at the time of their death; one report related to a detained patient.” (Page 27)
I have found by searching information uploaded by the Chief Coroners’ office, that there were at least 92 Reports to Prevent Future Deaths on mental health service patients in the period 2014/2015.
Additionally, six of the 92 reports related to detained patients.
Five of the 92 reports, which related to informal patients, appeared to have been copied to CQC by coroners. One of the five was sent to you personally. I provide links below to all five original reports.
I would be grateful to understand why CQC did not include all relevant data in its 2014/2015 report, particularly as it advised in its 2013/2014 report that:
“Coroners Society: In 2014 we developed a memorandum of understanding with the Coroners Society. We now receive information from individual coroners’ reports about any deaths in health and care settings and how these could be prevented in future.” (Page 33)
Yours sincerely,
Dr Minh Alexander
cc Health Committee
Chairs of Public Accounts and Public Administration and Constitutional Affairs
Committee
AvMA
INQUEST
Keith Conradi Chief Investigator HSIB
Five coroners’ Reports to Prevent Future Deaths that were apparently copied to CQC by coroners in 2014/2015:
https://www.judiciary.gov.uk/publications/james-boylan/
https://www.judiciary.gov.uk/publications/simon-costin/
SHARMILA CHOWDHURY 
Another important question to ask of the CQC is what they do with Prevention of Future Death Reports and other concerns expressed by Coroners.
My research found a case (Victoria Nye – deceased) in which a Consultant Psychiatrist shredded his notes before the Inquest. The Coroner’s Manager told me it had been reported to the CQC but the General Medical Council knew nothing of the case. It was evident that CQC (and the Trust) failed to report the Consultant to the GMC for what clearly is serious (if not gross) professional misconduct – and potentially perverting the course of justice.
In my opinion Coroners should report concerns about a specific professional straight to the relevant Regulator – not rely on the CQC to do so.
The name of the Trust will not come as a surprise to anyone, who has watched the news recently – read more at https://999crash.wordpress.com/blog/
Pingback: NHS whistleblowing articles in 2016: TWO years post Francis Review with NO change | sharmilachowdhury