Care Quality Commission: Deaths in Mental Health Facilities

Part of the debate – in the House of Commons at 2:32 pm on 16th October 2020.

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Photo of James Cartlidge James Cartlidge Conservative, South Suffolk 2:32 pm, 16th October 2020

I am very grateful to you, Mr Deputy Speaker, for enabling this debate to come forward, and I will entirely abide by your guidance on the case that is ongoing. It highlights, frankly, that this is a very timely debate. Your guidance in relation to the case means that there are important points of substance that I am unable to make today, but the fundamentals are unchanged because, as you say, they relate to a death in May 2015 under the Care Quality Commission rather than the Health and Safety Executive.

The case in question is that of Richard Edward Wade of Great Cornard in South Suffolk, and the failure of the Care Quality Commission to investigate his death and provide his family with the justice and accountability that they have sought for so long. On the evening of 16 May 2015, Richard called the police as he was suffering from poor mental health and feared that he would hurt himself. The police assessed him and decided that the best course of action would be to admit him to the Linden Centre in Chelmsford to ensure his safety. I emphasise that Richard voluntarily called for assistance, he was not sectioned, and he was admitted to the Linden Centre on the basis that it would provide a place of care.

Just over 12 hours later, Richard was found to have attempted suicide by use of a ligature. Richard was transferred to the Broomfield Hospital next door, received treatment in the intensive care unit, and passed away on 21 May 2015. Richard, who had a PhD in political science and had published a book two years before, was just 30 years old when he died.

Before I set out my primary arguments about the CQC’s handling of the case, I would like to make three important points. First, I would like to take this opportunity to pay tribute to Richard’s parents, Linda and Robert Wade, who, despite their tragic loss, have shown remarkable resilience in their fight for justice. They have never given up pursuing the truth and I sincerely admire the way they have been able to maintain outer calm whenever describing to me and others, including the Minister, the traumatic details of their son’s last days.

The Minister I refer to is the Minister for Patient Safety, Mental Health and Suicide Prevention, my hon. Friend Ms Dorries. She cannot be here today; the Minister for Health, my hon. Friend Edward Argar, is covering, but my second point is to pay tribute to my hon. Friend the Mental Health Minister, because she has shown huge personal interest in this case. Back in October, when she met the parents of Richard Wade, she was incredibly moved by what she heard. As the son of a nurse—my mother was a nurse for many decades—I would say that my hon. Friend’s background as a nurse shone through. She showed genuine empathy and sympathy with the Wades, and I know that she has been trying her best in the background to get proactive stuff done on the case.

My third point before I go into my main remarks is that I am very much aware that this is not the only death that has occurred by ligature at the Linden Centre Chelmsford. There are a number of cases with circumstances not dissimilar to those of Richard Wade. For example, Mr Deputy Speaker, you may be aware that the Petitions Committee has received a petition for a public inquiry into one such case that has now received more than 100,000 signatures. I believe that the case for a public inquiry or an independent inquiry is very strong, particularly in the case of Richard Wade, because, in demonstrating how the CQC failed to investigate his death, it prompts the following very simple question. Since that investigation timed out under its statutory time limit, if not an independent inquiry, what else can we offer the Wades in their search for the truth of what happened to their son?

Of course, primary responsibility for the handling of Richard’s clinical case in May 2015 rested with the trust in charge of the Linden Centre, then the North Essex Partnership NHS Foundation Trust and now the Essex Partnership University NHS Foundation Trust, which I will refer to from now on as “the trust”. In January 2016, following an internal investigation into Richard’s death, the Wades received a letter of apology from Andrew Geldard, the chief executive of the trust, stating that Richard’s death in the trust’s care “could have been avoided”. My primary concern today is not the role of the trust but that of the regulator charged by the Department of Health with the legal responsibility for holding the trust to account for its failings, the CQC.

The facts of timing are critical here. In April 2015, following recommendations in the Francis report, which came from the Mid Staffordshire scandal, prosecuting powers in relation to patient care passed from the Health and Safety Executive to the CQC. Richard died a month after the transfer of responsibilities, but, agonisingly for Richard’s parents, through a series of internal failures at the CQC the regulator failed to prosecute the trust within its three-year statutory limit. The main reason for the failure to prosecute is very hard to take, and is evidenced by the CQC’s own internal report into the handling of Richard’s case, published this July, which is the primary document to which I shall be referring.

The report states that the

“CQC did not undertake its own review or investigation of Richard’s death as staff, who acted as the relationship owner for this location, mistakenly believed that HSE retained primacy of the criminal investigation alongside Essex police”.

In short, the CQC did not investigate because it did not realise it was its responsibility to do so. What reason was given for this shortcoming? The report says that the CQC was “unprepared” for the changes of April 2015, stating:

“The implementation of new powers of criminal enforcement had been given to us at short notice”.

I repeat “short notice”, because that is simply not the case. In fact, these new powers were passed in the Commons in 2014 in the form of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, giving the CQC plenty of time to ensure that its staff were properly informed and trained in these new powers.

In February 2015, the CQC published its “Enforcement policy” document for its staff ahead of gaining the new powers in April 2015. This policy clearly states:

“CQC is the lead inspection and enforcement body for safety and quality of treatment and care matters involving patients and service users in receipt of health or adult social care service from a provider registered with CQC”.

I can also confirm that in the run-up to the CQC taking lead responsibility after April 2015, there was close working between the HSE and the CQC, which included not only a memorandum of understanding to clarify roles and responsibilities, but interim working arrangements and, crucially, training for CQC staff on criminal investigations. It is very hard to believe that CQC inspectors did not know of the new powers at the time of Richard Wade’s death. If it is true that they did not know, it represents gross negligence and a manifest failing on the part of senior CQC management for which nobody has been held to account to date.

The CQC did eventually hold a management review meeting about Richard’s case in May 2017, two years after his death, due to the impending coroner’s inquest, and in July 2017 a lawyer was finally allocated to the case. Over the next six months, because of “staffing continuity issues”, the lawyer changing three times and a lack of response from Essex constabulary, very little progress was made in Richard’s case. According to the report,

“by the time the police provided some evidence on 6 January 2018, the impending limitation date of 17 May 2018 left insufficient time for the case to be considered from a fully informed evidential position, with a view to a potential prosecution.”

Put simply, instead of using those final four months of the three-year time limit to commence the investigation, which, after all, was running late precisely because of mistakes made by the CQC, it would appear that at that stage the CQC simply gave up.

Last week the CQC announced that it would be prosecuting the East Kent Hospitals University NHS Foundation Trust, following complications that led to the death of a baby in its care in November 2017. This is the first time that the regulator has prosecuted an NHS trust over a safety failure in the clinical care of patients since it gained the powers in 2015. For Mr and Mrs Wade it has been a painful reminder of what might have been. As I said at the beginning, there have been a number of other cases at the Linden Centre not dissimilar to Richard Wade’s.

In addition to the failure to investigate within the statutory time limit, the other shocking aspect of the CQC’s handling of his death was its failure to see a wider pattern—surely this goes to the very purpose of the regulatory changes that followed the infamous Mid Staffs scandal. In February 2015, just three months before Richard died, another patient died from ligature compression to the neck in the Linden Centre. This occurred in the very same bathroom where Richard attempted to take his life on 17 May 2015. We know that the CQC first became aware of Richard’s case on 18 May 2015. On 20 May 2015, while Richard was in intensive care in Broomfield Hospital, the CQC published its report into the February incident. Richard was pronounced dead the next day. In that context, surely one would have expected alarm bells to be ringing and klaxons to be sounding. The CQC was suddenly aware of two similar deaths by ligature, not only in the same setting but in the same bathroom, but nothing happened—there was no investigation and no emergency investigation. Given the similarity of these cases, I find that extraordinary.

The trust carried out its own serious incident investigation into Richard’s death in December 2015, and the CQC report notes that

“it does not mention that a patient had used a ligature in the same bathroom three months before this accident, and subsequently died”.

Yet there was no challenge to this glaring omission from the CQC and its report states that

“there is no documentary evidence that CQC reviewed evidence and judged if the recommendations from the serious incident were embedded”.

Perhaps most worrying of all, the CQC inspection that occurred into the February 2015 death was a missed opportunity to prevent Richard’s own tragedy. The report on Richard’s death explains that there is no documentary evidence that the February 2015 inspectors gave verbal feedback to the trust about the actions that needed to be taken to prevent another death. Additionally, it states that they

“have no evidence in our records of any action the trust took following feedback from inspectors. After the 2015 inspection, the trust was asked to provide further information regarding environmental risk assessments and care plan reviews. However, there is no documentation of CQC formally reviewing this extra evidence that the trust submitted.”

At every turn, there was inaction by the CQC until it was too late.

That brings me to my final points. In October last year, the Public Administration and Constitutional Affairs Committee held an evidence session on the Parliamentary and Health Service Ombudsman’s report on missed opportunities at the trust. The report focused on the cases of two victims, who did not including Richard Wade, and Mr and Mrs Wade provided written evidence about Richard’s death. During the session, my hon. Friend the Minister for Patient Safety, Mental Health and Suicide Prevention explained that the Department’s position on the calls for a public inquiry was that such inquiries

“do not happen for individual cases;
they tend to happen when there is a systemic problem or there are multiple cases. In this case, a public inquiry is not an appropriate response because we are talking about two cases.”

There are multiple cases. I believe there is strong evidence of systemic failure, and on top of that we now have regulatory failure. As such, I believe it is time for the Minister to consider the need for an independent inquiry into all similar deaths at the Linden Centre, including that of Ricard Wade.

A young man lost his life in the place where he had sought safety. Richard identified that he was a risk to himself and asked our mental health service for assistance. Due to multiple missed opportunities for existing problems to be rectified, he lost his life. Now, his family are being denied the justice that they deserve through patent failures by the CQC within the statutory time limit that has now closed. There is no statutory time limit on the grief of his parents. All they want is to know the truth. If that can come from an independent inquiry, that is the least we can do for them. My hon. Friend the Minister for Patient Safety, Mental Health and Suicide Prevention has been sympathetic and I know she is doing all she can in the background. I hope that today my hon. Friend the Minister for Health can give us some hope for the future.