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, accused his carer of instigating a “cover-up” of how he died and frustrating her efforts to get to the truth.
The Ombudsman has criticized the Care Quality Commission (CQC) for failing to act on evidence emerging at the inquest into the boy’s death which cast doubt on the trust’s version of events.
The ruling by ombudsman Rebecca Hilsenrath is a further blow to the credibility of the QC, which Health Minister Wes Streeting declared in July to be “unfit for purpose”.
Hilsenrath said the case shows that the various regulatory bodies that monitor the health sector need to ensure that when mistakes are made, the care provider shows transparency and accountability.
The ombudsman did not mention the boy’s name. He had neurological disabilities and lived in Sheffield with his foster parents, who cared for him from the time he was six months old. He was found dead in his bed one morning in May 2017, after six weeks in a specialist residential home for children in Tadworth, Surrey, run by Children’s confidenceCharitable foundation.
He was doing well and had no major physical or medical concerns. Initially, the CQC believed his death was natural, based on what the charity said.
But an investigation into his death found it occurred after the padded bumper around his bed, to prevent injuries or falls, was removed and secured under his neck. It found that he died “after becoming wedged in a loose bed bumper, causing death by airway obstruction.”
The boy’s foster mother, who asked to remain anonymous, complained to the QC and, unhappy with its response, raised her concerns with the ombudsman.
“When things go wrong in care, there must be accountability and lessons must be learned. If not, grieving families suffer the added pain of having to fight harder to get the answers they are looking for,” Hilsenrath said.
“Regulatory organizations must ensure that all available evidence is examined to reveal the truth to everyone involved and to prevent others from experiencing the same trauma.”
Dr Karen Henderson, the coroner who heard the inquest, was so concerned by the evidence given about the Children’s Trust’s behavior that she issued a report to prevent future deaths – a legal warning that the risks of the same events occurring should be eliminated to protect patients.
She stressed in the report that police and forensic staff who attended the trust shortly after the boy’s death “were not fully aware of the circumstances of his death.” For example, they were not told what position his body was found in, that he had been dead “for some time” or that a bumper was found around his neck.
The trust “has not acknowledged that there is a lack of transparency and openness about how this is done.” [the boy] The coroner added: “He died or the trust did not properly investigate his death or inform the relevant legal bodies of the circumstances of his death.”
Following the investigation, the Children’s Trust said it accepted the coroner’s findings and apologized to the boy’s family. “Our senior leadership team has established a dedicated working group to develop new processes and systems that will address coroner concerns,” she said in a statement at the time.
“This is in addition to the measures we have already taken in the past five years since then [the boy’s] death; Including new beds and cots, and changes to our night watch policy.
Speaking to The Guardian, the boy’s adoptive mother said: “I think there is no doubt that there was a cover-up.” [by the trust]. I feel really angry. I feel it [her son’s] Life doesn’t matter.
“The CQC should have been more inquisitive. As a doctor, I’m used to dealing with the CQC. But I lost faith in the organization that should be doing everything it can to make sure places looking after vulnerable people are safe. They didn’t see that things weren’t adding up here .
“I felt the CQC was there to protect the trust and its reputation. The Ombudsman is the only one who gets answers for me, because they won’t give me any.
James Bullion, CQC chief inspector of adult social care and integrated care, admitted the regulator had failed the boy’s family.
“Everyone has the right to expect safe, high-quality care and a regulatory body they can trust to act in their and their loved ones’ best interests. We fell short in this case and are deeply sorry for the impact this has had on this young boy’s family.”