20 Jun 2013

CQC bosses behind baby deaths ‘cover-up’ revealed

Former CQC boss Cynthia Bower, her former deputy Jill Finney and current CQC media manager Anna Jefferson are named as the officials accused of covering up inspection failures at a Cumbrian hospital.

The Care Quality Commission (CQC) had originally redacted the senior managers’ names from a damning report which detailed the alleged cover-up of an internal review highlighting a failure of inspections of Morecambe Bay NHS Trust.

The report described how “Mr G”, who we now know was Jill Finney, uttered the ominous words “read my lips” when telling the author of the report to get rid of it.

Current CQC media manager Anna Jefferson was quoted in the report as saying “are you kidding me? This can never be in a public domain, nor subject to FoI (Freedom of Information request)”.

Louise Dineley, the author of the damning internal report, told independent investigators that Ms Finney had ordered the deletion of the report and that Ms Bower and Ms Jefferson had “verbally agreed”.

Cynthia Bower, former chief executive of the CQC, and her deputy, Ms Finney, have since left the CQC, but Ms Jefferson is still in post.

Are you kidding me? This can never be in a public domain, nor subject to FoI – Anna Jefferson, CQC media manager

The health regulator had come under increasing pressure to release the names after pressure from ministers including Health Secretary Jeremy Hunt, and the names were eventually released on Thursday afternoon.

Mr Hunt said the decision to publish the names was “a sign that the NHS is changing”. “It’s to the credit of the new management of the CQC that they got an independent report and did not run away from this problem,” he added.

The four officials sat around the table at a key private CQC meeting in March 2012 when the decision was allegedly taken to cover-up evidence of the failures at Morecambe Bay NHS Trust – and the failures of the CQC’s initial inspection to pick up on what was going wrong.

Denials of deletion

Cynthia Bower, 57, became CQC chief executive in 2008 but left the organisation last year after the publication of a report, critical of the CQC, with a pension pot of over £1.3m. In a statement, she said she regretted any regulation failings, but denied ordering that the critical report be deleted.

“I gave no instruction to delete any such report; I have no note or recollection of such instruction being given. Had I heard any such instruction, I would have countermanded it.

“The report was, in fact, never deleted and indeed a copy was provided to Grant Thornton,” she said in a statement.

Ms Finney was behind the CQC’s response to the Francis report into the Mid Staffs scandal. She was on a salary of up to £145,000 after being appointed Ms Bower’s deputy and director of communications and marketing in 2009, but left the CQC in February and now works for the internet company Nominet.

According to her LinkedIn profile, Ms Jefferson has been at the CQC since February 2003. She also denied the allegations, and said the quote attributed to her was “false, uncorroborated and has since been retracted, I am appalled that it appears in the report”.

Baby deaths

Police are still investigating the death of nine-day-old baby Joshua Titcombe, who died in 2008 at Furness General Hospital, which was run by University Hospitals of Morecambe Bay NHS Trust. On Thursday, officers said they would widen the investigation to cover other deaths, following the critical report.

James Titcombe, Joshua’s father, tweeted that he felt “disgust” about Ms Bower’s involvement in the cover-up (see below).

More than 30 families are involved in legal action against the Cumbrian hospital, and while police have not confirmed numbers, up to 16 babies and two mothers are feared to have died because of poor care between 2001 and 2012.

Private CQC meeting

At the private 2012 meeting, CQC board members were told that a 2010 inspection of the hospital had given the trust a clean bill of health, despite concerns over the deaths of mother and babies, and the hospital’s high mortality rate.

They were showsn an internal report by Ms Dineley, carried out a year later, which condemned the inspectors for failing to double-check evidence given and not being thorough enough in its investigation.

But the health watchdog bosses were so concerned about the review’s critical findings that they ordered it to be quashed, according to a review by Grant Thornton.

The details of the cover-up finally emerged in a damning report into the way the CQC carried out its inspections, published on Wednesday.

It’s to the credit of the new management of the CQC that they got an independent report and did not run away from this problem – Jeremy Hunt

The new management at the CQC said they had been advised not to name those involved for legal reasons, but on Thursday the Information Commissioner warned against hiding behind the Data Protection Act, and said that there was a strong public interest in releasing the names.

In a letter to Mr Hunt, CQC leaders David Prior and David Behan they had revised the decision following fresh legal advice.

“Since the publication of the report we are seeking advice on whether there is any appropriate action that might be taken in relation to the named individuals and will keep you advised of this,” the letter continued.

Labour’s role in CQC

Mr Hunt told MPs that Labour should shoulder some of the blame for the way the CQC was set up in the first place.

On Wednesday Mr Hunt told the House of Commons that if Labour took the issues raised by the Morecambe Bay NHS Trust scandal seriously, “they would recognise that it was fundamentally wrong to set up inspection regimes not being done by specialists: where the same person is inspecting a dental clinic, a slimming clinic, a hospital or a GP practice, perhaps in the same month and that may have contributed to why in 2009 the CQC did not decide to investigate the maternity deaths at Morecambe Bay.”

The CQC was established by Labour in 2009 under the Health and Social Care Act, and took over from three regulatory bodies.

Mr Titcombe, who has been a driving force behind the campaign group Morecambe Bay Inquiry Action (MBIA), said the actions of those at the very top of the Department of Health needed to be investigated. “MBIA will only accept apology from @andyburnhammp AFTER a wider inquiry confirms no wrongdoing by Ministers & DoH,” he tweeted.

Morecambe Bay NHS Trust – Timeline

Oct 2008 – Nine-day old baby Joshua Titcombe dies at Furness maternity hospital, part of University Hospitals of Morecambe Bay NHS Trust.

2009 – His father, James Titcombe, calls for an inquiry into what went wrong.

June 2010 – CQC visits Furness General Hospital and gives the trust a clean bill of health, despite the hospital having highest mortality rate in the country.

April 2011 – Kelly Hine’s baby Amelia dies of asphyxiation at Furness maternity hospital.

June 2011 – Cumbria police begin an investigation into Joshua Titcombe’s death.

Nov 2011 – Kay Sheldon, non-executive director at the CQC, tells the Francis inquiry into the Mid Staffs Trust that training for NHS inspectors is appallingly bad.

Dec 2011 – CQC orders an internal investigation of the Morecambe Bay NHS Trust.

Feb 2012 – At a CQC board meeting, Kay Sheldon asks why action wasn’t taken sooner – but is not told that a report is underway.

March 2012 – At a private CQC meeting, four officials discuss Morecambe Bay Trust. The decision is taken to hide the internal report, because of its damning criticism of the CQC’s inspection process.

April 2012 – CQC board meets, but Morecambe Bay NHS Trust is not discussed

Feb 2013 – The Francis Report into Mid Staffs Trust is published and recommends a reform of inspection teams to include doctors and nurses.