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 boy's care provider of instigating a “cover-up” of the circumstances of his death and frustrating her efforts to find out the truth.
The ombudsman criticized the Care Quality Commission (CQC) for failing to act on evidence revealed at the inquest into the boy's death which called into question the trust's position.
Ombudsman Rebecca Hilsenrath's ruling was a further blow to the credibility of the CQC, which was declared “unfit for purpose” by Health Secretary Wes Streeting in July.
This case shows that the various regulatory agencies that oversee the healthcare sector need to ensure that healthcare providers demonstrate transparency and accountability when mistakes are made, Hilsenrath said. .
The ombudsman did not release the boy's name. He had a neurological disorder and lived in Sheffield with foster parents who had cared for him since he was six months old. He was found dead in his cot one morning in May 2017, after six weeks at a specialist residential children's home in Tadworth, Surrey. Children's Trustcharity work.
He was in good spirits and had no underlying physical or medical concerns. CQC initially believed his death was due to natural causes, based on what the charity had told him.
However, an inquest into his death found that death occurred after a padded bumper around his bed to prevent injuries and falls came loose and became lodged under his neck. The investigation found that the man “died of airway obstruction due to being trapped by a loose cot bumper.”
The boy's adoptive mother, who did not wish to be named, lodged a complaint with the CQC and, dissatisfied with the response, raised her concerns with the Ombudsman.
“When things go wrong in care, accountability must be held and lessons must be learned. If that doesn’t happen, grieving families will have to fight harder to get the answers they are looking for. You will suffer the added pain of not being able to do so,” Hilsenrath said.
“Regulatory bodies must ensure that all available evidence is investigated to uncover the truth for everyone involved and to prevent others from experiencing the same trauma.”
Coroner Dr Karen Henderson, who heard the inquest, was so concerned by the evidence given about the actions of the Children's Trust that she published the Preventing Future Deaths report. This is a legal warning that the risk of the same event occurring must be eradicated to protect patients.
In her report, she highlighted that police and Colonial staff who attended the trust shortly after the boy's death were “not fully informed of the circumstances of his death”. For example, they were not told in what position the body was found, that it had been “some time” since death, or that there was a bumper around its neck.
The trust “does not accept that there was a lack of transparency and openness about how this was done.” [the boy] “Either he died or the trust failed to properly investigate his death or inform the relevant statutory bodies 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 to address coroners' concerns.
“This is in addition to the measures we have already taken over the past five years. [the boy’s] death; includes new beds and cots, and changes to nighttime monitoring policies. ”
The boy's adoptive mother told the Guardian: [by the trust]. I feel really angry. I feel like [her son’s] Life didn't matter.
“The CQC should have been more curious. As a doctor, I am used to dealing with the CQC, but I would like to make sure that the places where we look after vulnerable people are safe. They lost faith in the organization that was supposed to be doing everything they could. They didn't realize that things weren't going well here.
“I felt like the CQC was there to protect trust and reputation. The only person who can give me answers is the Ombudsman, because they don’t give me any answers.”
James Bullion, CQC's chief inspector of adult social and integrated care, admitted the regulator had let the boy's family down.
“Everyone has the right to expect safe, high-quality care and regulators they can trust to act in their best interests and the best interests of their loved ones. We are falling short in this case.” We deeply apologize for the impact this has had on this boy's family.”
