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 unit.
The boy’s foster mother – an NHS doctor – has accused the care provider who looked after him of instigating a “cover-up” about how he died and thwarting her efforts to get to the truth.
The ombudsman has criticized the Care Quality Commission (CQC) for failing to act on evidence revealed in its investigation into the boy’s death, which casts doubt on the trust’s version of events.
The decision by ombudsman Rebecca Hilsenrath is another blow to the credibility of the CQC, which Health Secretary Wes Streeting declared “not fit for purpose” in July.
The case shows that the various regulators who oversee the health sector need to ensure that care providers demonstrate transparency and accountability when mistakes are made, Hilsenrath said.
The Lokpal did not reveal the name of the boy. He suffered from neurodisabilities and lived with foster parents in Sheffield, who looked after him from the age of six months. He was found dead in his cot one morning in May 2017, after living for six weeks in a specialist residential children’s home in Tadworth, Surrey, which was run by the charity. children’s trusta charity.
He was doing well and had no major physical or medical concerns. At first, based on what the charity had reported, the CQC believed his death was natural.
But the inquest into his death found that the death was caused by a loosely padded bumper around his cot, which protected against injuries or falls, had disintegrated and become trapped under his neck. It found that he died “after becoming entangled in a loose cot bumper, leading to airway obstruction”.
The boy’s foster mother, who asked to remain anonymous, complained to the CQC and, dissatisfied with its response, raised her concerns with the ombudsman.
“When things go wrong in care there must be accountability and lessons learned. If that doesn’t happen, bereaved families have to endure the added pain of struggling even harder to get the answers they’re 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 presented about the behavior of the Children’s Trust that she issued a prevention of future deaths report – a legal warning that similar incidents should be avoided in order to protect patients. The threats must be eliminated.
In the report, they highlighted that police and coronial staff attending the trust immediately after the boy’s death “were not fully informed about the circumstances of his death”. For example, they were not told the condition in which his body was found, that he had been dead “for some time” or that the bolus was found across his neck.
The Trust “does not accept that there was a lack of transparency and openness” [the boy] died or the Trust did not properly investigate his death or notify the relevant statutory bodies about the circumstances of his death”, the coroner said.
Following the inquest, the Children’s Trust said it accepted the coroner’s findings and apologized to the boy’s family. In a statement at the time, it 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 have already implemented over the past five years [the boy’s] Death; “That includes new beds and cots and changes to our overnight 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’m really angry. i feel like [her son’s] Life doesn’t matter.
“The CQC should have been more keen. As a doctor, I am used to dealing with CQC. But I have lost all confidence in an organization which should be doing everything possible to ensure that places that care for vulnerable people are safe. He didn’t see that things weren’t adding up here.
“It felt as if the CQC was there to protect the trust and its reputation. It’s only the Lokpal who has answered me, because they won’t give me any answers.”
James Bullion, the CQC’s chief inspector of adult social care and integrated care, admitted the regulator had let the boy’s family down.
“Everyone has the right to expect safe, high-quality care and a regulator they can trust to act in the best interests of themselves and their loved ones. “We missed the mark in this matter and are deeply sorry for the impact it has had on this young boy’s family.”