This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government
Statement by the Secretary of State for Health in relation to the report into maternity services at Morcambe Bay.
I wish to make a statement about today’s independent report into the CQC’s regulatory oversight of University Hospitals Morecambe Bay.
What happened at Morecambe Bay Hospital is, above all, a terrible personal tragedy for all of the families involved.
Before saying anything else I want to apologise on behalf of the government and the NHS for all the appalling suffering they have endured - and in that context I know the whole House will wish to extend our condolences to every one of them.
Joshua Titcombe’s tragic death was one of 12 serious untoward incidents, including five in the maternity department. His family and others have had to work tirelessly to expose the truth and I want to pay tribute to them for that. But the fact is they should not have had to go to the lengths they have.
As we saw with Mid Staffs, a culture in the NHS had been allowed to develop where defensiveness and secrecy were put ahead of patient safety and care.
Today I want to explain to the House what the Government is doing to root out this culture and ensure this kind of cover up never happens again.
This independent report was commissioned by the new Chief Executive of the CQC and the new team running the organisation have made it clear there was a completely unacceptable attempt to cover up the deficiencies in their organisation.
The report lists what went wrong over many years: unclear regulatory processes; reports commissioned and then withheld; lack of sharing of key information; and communication problems throughout the organisations. Most of the facts are not in dispute. All of them are unacceptable. They have compounded the grief of the Titcombe family and many others.
The role of the regulator is to be a champion for patients, to expose poor care and make sure steps are taken to root it out. It must do this without fear or favour. It is clear that at Morecambe Bay the CQC failed this fundamental duty. We now have new leadership at the CQC and we should recognise their role in turning things around. David Behan was appointed Chief Executive in July 2012. One of his very first acts was to commission the report we are now debating. David Prior was appointed the new Chairman in January this year. He has rightly insisted this report be published as soon as possible.
These two outstanding individuals have never shrunk from addressing head on the failings of the organisation they inherited and are wholly committed to turning the CQC into the fearless, independent regulator this House would like to see. Whilst I do not underestimate their challenge, I have every confidence in their ability to undertake it.
David Prior will now report back to me on what further actions the CQC will take in response to this report, including internal disciplinary procedures and any other appropriate sanctions on individuals. The whole truth must come out and individuals held to account.
Working with the CQC and following the Francis report into the tragedy at Mid Staffs, the government is putting in place far-reaching measures to put patient care and patient safety at the heart of how the NHS is regulated.
The CQC is appointing three new Chief Inspectors - of Hospitals, Social Care and General Practice. This will provide an authoritative, independent voice on the quality of care in all the providers that they regulate.
The Commission has already announced the appointment of Professor Sir Mike Richards as the new Chief Inspector of Hospitals. And, on Monday, the CQC launched a consultation, A new start, which outlines its much tougher regulatory approach. This includes putting in place more specialist inspection teams with clinical expertise. It will include Ofsted-style performance ratings so that every member of the public can know how well their local hospital is doing - just as they do for their local school. The Government will also amend the CQC registration requirements so that they include an emphasis on fundamental standards – the basic levels below which care must never fall, such as making sure patients are properly fed, washed and treated with dignity and respect. Failure to adhere to these will result in serious consequences for providers, including potentially criminal prosecution.
The revised registration requirements will also include a new statutory duty of candour on providers that will require them to tell patients and regulators where there are failings in care, a failure that was clearly identified in today’s report.
Finally, we are putting in place, through the Care Bill, a new robust single failure regime for NHS hospitals. This will provide a more effective mechanism to address persistent failings in the quality of care, including the automatic suspension of Trust Boards when failings are not addressed promptly. The events at Morecambe Bay, Mid Staffs and many other hospitals should never have been covered up. But they should never have happened in the first place either. To prevent such tragedies, we need to transform the approach to patient safety in our NHS.
The Prime Minister has therefore asked Professor Don Berwick, President Obama’s former health advisor and one of the world’s foremost experts on patient safety, to advise us on how to create the right safety culture in the NHS. He and his committee will be reporting later this summer. In addition, later this year, we will start to publish surgeon-level outcomes data for a wide range of surgical specialities.
Most of all, we need a culture where from the top to the bottom of NHS organisations everyone is focused on reducing the chances of harming a patient in the course of their care.
And a culture of openness and transparency to ensure that when tragedies do occur, they are dealt with honestly so that any lessons can be learned.
Our thousands of dedicated doctors, nurses and healthcare assistants want nothing less. We must not let them down, nor the families who suffered in Morecambe Bay.